Physician goals: impact on hospital performance

Controversy prevails concerning the relative superiority of for-profit versus not-for-profit hospitals. Presented here are three variations to each of two basic theoretical models that contrast performance of for-profit and not-for-profit hospitals.     

2000年世界卫生报告:拓展卫生系统绩效的视野

2000年世界卫生组织报告的10周年纪念,为我们提供了一个绝佳的机会,去重新审视报告的发布和随后引发的讨论,这种审视有利于客观地认识和理解各种争议、达成新的共识,并使讨论更有价值和更深入。     

Setting goals and targets for performance standards within the Swedish health care system

The development of any health care system towards setting goals and targets and intended outcomes--with national guidelines, a legislative framework, limited resources, consumer influence and competitive forces--makes great demands on the control mechanisms required. The Swedish health care system has no tradition of goal formulation of this type. Hence, the purpose of this article is to clarify the goal-setting process of performance standards, and to examine whether goal setting is a relevant method within the organization of a Swedish county council. Goal setting can be seen partly as a control method and partly as an administrative process. The approach used is a combination of qualitative and quantitative methods. Data have been collected from interviews, observations, notes taken in the field and available performance statistics. The analysis shows that working towards a goal is made easier through a common and simple concept. It 'stands and falls' with the management of the work and its manager. Good communications and information are important prerequisites if goal formulation, through dialogue, is to succeed. This process takes time and can be described as an iterative process, in which a common behaviour pattern develops a 'we-feeling' which spreads among the staff. It is important that the goal is relevant and directly related to the basic objects of the work. It is also crucial that the goal is realistic and reflects a priority. Goal formulation relating to performance standards can be a contributing factor to staff's experience of job satisfaction through increased engagement and motivation, and to the satisfaction of patients/relatives with the care given. It is difficult to formulate performance standards; there are many problems and obstacles. If goal formulation as a control method within the health care system in Sweden is to work, clearer manifestations of political will are necessary and also better measuring methods in order to guage achievement.     

The public versus the World Health Organization on health system performance

The World Health Organization (WHO) ranked health systems in 191 countries based on measures developed by public health experts. This paper compares the WHO rankings for seventeen industrialized countries with the perceptions of their citizens. The results show little relationship between WHO rankings and the satisfaction of the citizens who experience these health systems. The health systems of some top WHO performers are rated poorly by their citizens, including the low-income and elderly. The two rated most highly by the public rank at the bottom of the WHO ratings. These findings suggest that both public and expert views should be considered in international rankings.     

Factors associated with preferences for health system goals in Japan: a pilot study of the World Health Survey

Preferences among people for health system goals are important determinants in developing health policy. The aim of this study was to determine preferences for health system goals and their associations with sociodemographic characteristics in Japan. Participants were randomly selected from the general population in 5 prefectures and were asked to rank 5 health system goals in order of preference: health, health inequality, responsiveness, responsiveness inequality, and fair financing. Associations between sociodemographic characteristics and preferences for health system goals were examined using multinomial logistic regression analysis. A total of 4936 persons responded to this study. Health system goals in order of preference were health inequality (37.6%), responsiveness inequality (20.9%), health (18.4%), responsiveness (16.0%), and fair financing (7.1%). Sociodemographic characteristics such as gender, age, family status, education completed, and usage of health care services were associated with the preferred health system goal. Health policy makers should take these associations into account when developing prospective policy.     

A critique of the World Health Organisation's evaluation of health system performance

The World Health Organisation's (WHO) approach to the measurement of health system efficiency is briefly described. Four arguments are then presented. First, equity of finance should not be a criterion for the evaluation of a health system and, more generally, the same objectives and importance weights should not be imposed upon all countries. Secondly, the numerical value of the importance weights do not reflect their true importance in the country rankings. Thirdly, the model for combining the different objectives into a single index of system performance is problematical and alternative models are shown to alter system rankings. The WHO statistical analysis is replicated and used to support the fourth argument which is that, contrary to the author's assertion, their methods cannot separate true inefficiency from random error. The procedure is also subject to omitted variable bias. The econometric model for all countries has very poor predictive power for the subset of OECD countries and it is outperformed by two simpler algorithms. Country rankings based upon the model are correspondingly unreliable. It is concluded that, despite these problems, the study is a landmark in the evolution of system evaluation, but one which requires significant revision.     

Policy coherence,health and the sustainable development goals: a health impact assessment of the Trans-Pacific Partnership

The international community, comprised of national governments, multilateral agencies and civil society organisations, has recently negotiated a set of 17 sustainable development goals (SDGs) and 169 targets to replace the Millennium Development Goals, which expired in 2015. For progress in implementing the SDGs, ensuring policy coherence for sustainable development will be essential. We conducted a health impact assessment to identify potential incoherences between contemporary regional trade agreements (RTAs) and nutrition and health-related SDGs. Our findings suggest that obligations in RTAs may conflict with several of the SDGs. Areas of policy incoherence include the spread of unhealthy commodities, threats to equitable access to essential health services, medicines and vaccines, and reduced government regulatory flexibility. Scenarios for future incoherence are identified, with recommendations for how these can be avoided or mitigated. While recognising that governments have multiple policy objectives that may not always be coherent, we contend that states implementing the SDGs must give greater attention to ensure that binding trade agreements do not undermine the achievement of SDG targets.     

Health priorities and public preferences: the relative importance of past health experience and future health prospects

We explore people's choices where the preference for those with worse future health prospects and the preference for the young over the old conflict. The empirical study used scenarios with four attributes: past years, past health, future years without treatment, and future health without treatment. One hundred respondents ranked various patient groups described in these terms. The results suggest a strong effect of past years: younger groups (40-year-olds) were always chosen over older ones (60-year-olds). Past health was significant in one question but not the other and future health and years without treatment were both non-significant.     

The relative influence of the community and the health system on work performance: a case study of community health workers in Colombia

A central component of the primary health care approach in developing countries has been the development and utilization of community-based health workers (CHWs) within the national health system. While the use of these front line workers has the potential to positively influence health behavior and health status in rural communities, there continues to be challenges to effective implementation of CHW programs. Reports of high turnover rates, absenteeism, poor quality of work, and low morale among CHWs have often been associated with weak organizational and managerial capacity of government health systems. However, no systematic research has examined the contribution of work-related factors to CHW job performance. The research reported in this paper examines the relative influence of reward and feedback factors associated with the community compared to those associated with the health system on the performance of CHWs. The data are drawn from a broader study of health promoters (CHWs) conducted in two departments (provinces) in Colombia in 1986. The research was based on a theoretical model of worker performance that focuses on job related sources of rewards and feedback. A survey research design was employed to obtain information from a random sample of rural health promoters (N = 179) and their auxiliary nurse supervisors about CHW performance and contributing factors. The findings indicate that feedback and rewards from the community have a greater influence on work performance (defined as degree of perceived goal attainment on job tasks) than do those stemming from the health system.(ABSTRACT TRUNCATED AT 250 WORDS)     

Measuring health system performance

The improvement of health system performance has become a key policy issue in most developed nations. To that end, many initiatives to measure system performance are being put in place. This paper examines the performance measurement movement from a principal/agent viewpoint. It argues that the effectiveness of performance measurement systems depends on four key factors: the extent to which the chosen performance measures reflect faithfully the objectives of the system, the nature and quality of the data, the incentives for clinicians to scrutinize and act upon the data, and the culture of the organization within which the data are deployed. Although the optimal design of performance measurement systems depends heavily on local factors, they are likely to offer a highly cost-effective instrument for securing major improvements in system performance if properly deployed     

An epidemiological study of the relative importance of damp housing in relation to adult health

STUDY OBJECTIVE: To examine the association between damp housing and adult health, taking into account a wide range of other factors that may influence health and could confound this relation. PARTICIPANTS AND SETTING: A general population sample of adults, aged 18-64, from Oxfordshire, Buckinghamshire, Berkshire and Northamptonshire. DESIGN: Secondary analysis of responses to a postal questionnaire survey carried out in 1997 with a 64% response rate (8889 of 13 800). Housing dampness was assessed by self report. Health was measured by responses to a series of questions including presence of asthma and longstanding illness generally, use of health services and perceived health status (the SF-36). The effect of damp was examined using the chi(2) test and one way analysis of variance. Significant associations with the various health outcomes were further explored taking into account 35 other housing, demographic, psychosocial and lifestyle variables using stepwise logistic and linear regression. MAIN RESULTS: Bivariate analyses indicated that damp was associated with the majority of health outcomes. Regression modelling however, found that being unable to keep the home warm enough in winter was a more important explanatory variable. Worry about pressure at work and to a lesser extent about money, showed an independent association with perceived health status equal to or greater than that of the housing environment, including cold housing, and that of health related lifestyles. CONCLUSIONS: This study shows that being unable to keep the home warm enough in winter is more strongly associated with health outcomes than is damp housing. However, as cold and damp housing are closely related, it is likely that their combined effects are shown in these results. The importance of worry as an independent predictor of health status needs testing in other studies. Its prevalence and relative importance suggest that it may be a significant determinant of public health.     

Quantifying the relative importance of predictors in multiple linear regression analyses for public health studies

Multiple linear regression analysis is widely used in many scientific fields, including public health, to evaluate how an outcome or response variable is related to a set of predictors. As a result, researchers often need to assess "relative importance" of a predictor by comparing the contributions made by other individual predictors in a particular regression model. Hence, development of valid statistical methods to estimate the relative importance of a set of predictors is of great interest. In this research, the authors considered the relative importance of a predictor when defined by that portion of the squared multiple correlation explained by the contribution of each predictor in the final model of interest. Here, a number of suggested relative importance indices motivated by this definition are reviewed, including the squared zero-order correlation, squared semipartial correlation, Product Measure (i.e., Pratt's Index), General Dominance Index, and Johnson's Relative Weight. The authors compared these indices using data sets from an occupational health study in which human inhalation exposure to styrene was measured and from a laboratory animal study on risk factors for atherosclerosis, and statistical properties using bootstrap methods were examined. The analysis suggests that the General Dominance Index and Johnson's Relative Weight are preferred methods for quantifying the relative importance of predictors in a multiple linear regression model. Johnson's Relative Weight involves significantly less computational burden than the General Dominance Index when the number of predictors in the final model is large.     

Assessing health system performance: A model-based approach

It is difficult to assess countries' relative success in addressing issues of public health because countries are subject to very different background conditions. To address this problem we offer a model-based approach for assessing health system performance. Specifically, an index of public health is regressed against a vector of variables intended to capture economic, educational, cultural, geographic, and epidemiological endowments. The residual from this model is regarded as a plausible measure of public health performance at the national level.We argue that a model-based approach to performance is informative for policymakers and academics as it focuses attention on those aspects of a country's health profile that are not constrained by structural factors. This sharpens comparisons across countries and through time, and also allows one to evaluate the degree to which health systems have lived up to their potential.     

Equity in health: the importance of different health streams

This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four 'health streams'. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far: and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health.