Health Care Services for HIV-Positive Substance Abusers in a Rural Setting: An Innovative Program

ABSTRACT

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care–related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand

The Thai government has implemented universal coverage of health insurance since October 2001. Universal access to antiretroviral (ARV) drugs has also been included since October 2003. These two policies have greatly increased the demand for health services and human resources for health, particularly among public health care providers. After the 1997 economic crisis, private health care providers, with the support of the government, embarked on new marketing strategies targeted at attracting foreign patients. Consequently, increasing numbers of foreign patients are visiting Thailand to seek medical care. In addition, the economic recovery since 2001 has greatly increased the demand for private health services among the Thai population. The increasing demand and much higher financial incentives from urban private providers have attracted health personnel, particularly medical doctors, from rural public health care facilities. Responding to this increasing demand and internal brain drain, in mid-2004 the Thai government approved the increased production of medical doctors by 10,678 in the following 15 years. Many additional financial incentives have also been applied. However, the immediate shortage of human resources needs to be addressed competently and urgently. Equity in health care access under this situation of competing demands from dual track policies is a challenge to policy makers and analysts. This paper summarizes the situation and trends as well as the responses by the Thai government. Both supply and demand side responses are described, and some solutions to restore equity in health care access are proposed.     

War-related changes in health and health services in Nicaragua

The low-intensity war against Nicaragua from 1983 to 1987 has had a wide reaching impact on health, health services, and health economics in that country. Beyond the death of individuals and destruction of facilities, economic embargo and contra destruction have cost the health system about 200 billion cordobas between 1981 and 1987. This is approximately equal to the value of 2 years of the entire health budget. The war has resulted in decreased accessibility and availability of services, leaving about 10% of the population without access to modern health facilities. Perhaps 10% of the demand for acute care services is generated by the war, which has resulted in a reorganization of surgical and medical services. Long term care needs for psychiatric illness and rehabilitation services are far more extensive. Population movements and resettlement, where preventive care has been unavailable, are associated with epidemics of malaria, diarrheal diseases, measles, leishmaniasis, meningitis, and tuberculosis. Health services remain a high priority of the government as health care is viewed as a way to reduce the untoward effects of the war on the general population. Nonetheless, the indirect effects of the war have been detrimental to the system. Negative effect include the loss to the system of health professionals and rampant inflation. These forces contribute to the weakening of primary health programs and the reorientation of the national system into hospital based, curative medical services.     

Health care services for HIV-positive substance abusers in a rural setting: an innovative program

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care-related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

提高福建省农村医疗卫生服务质量的探讨

调查表明,目前农村医疗卫生服务体系在不同地区发展不平衡;农民年医疗费用个体间差别很大,患重病的村民可能造成历病致贫现象。建议采取措施健全以乡镇卫生院为龙头的农村医疗医疗卫生服务体系网络,通过乡村一体化管理方式,不断提高服务质量,因地制宜建立农村社会医疗卫生服务保障制度。     

实施“农民健康工程”发展农村卫生事业

该文对山西省农村卫生工作做了大量调查,主要有4方面问题。1.农村三级医疗保健网基础设施建设严重滞后,工作用房维修改扩建任务重;2.乡镇卫生院设备陈旧落后,难以适应当前医疗卫生服务需要;3.乡村两级卫技人员素质偏低;4.有一定比例国家级和省级贫困县。因病致贫、因病返贫占贫困户的比例较大。针对以上问题,省委、省府把加强和完善农村三级医疗预防保健网建设、普及合作医疗和提高农村卫技人员素质作为“农民健康工程”来抓,其主要措施为：1．农村三级医疗预防保健网建设,到2000年全部实现“一无三配套”;2．普及农村合作医疗,到2000年全省80％以上的村卫生所要实现各种形式的合作医疗;3.乡村两级卫技人员培训,到2000年现乡、村两级无专业学历的卫技人员中80％以上要接受正规医学中专学历教育。     

云南省农村妇女生育健康基础服务需要量研究

采用问卷调查与收集现有资料相结合的方法,对云南农村已婚育龄妇女的生育健康基础服务需要量进行了调查研究。结果表明;农村妇女对生育健康服务的需要是综合性的,既包括预防性服务也包括治疗性服务;当前农村育龄妇女面临的主要生育健康问题是以妊高症为主的孕期并发症与合并症、产伤、产后出血、生殖道感染、避孕方法的副作用和并发症等;贫困妇女对服务的需要量更大。要有效地改善农村妇女的生育健康状况,有关部门应向其提供综合性的生育健康基础服务,并把主要生育健康问题列为工作重点。     

山东和宁夏6县新农合对妇幼卫生服务的报销制度安排研究

目的:分析研究地区新农合对妇幼卫生服务的报销制度安排。方法:分层随机抽取山东和宁夏6个县,分析当地的新农合方案,并深入访谈相关工作人员。结果:山东和宁夏6个县的新农合服务包都包括了一些妇幼卫生服务,根据纳入服务的不同,分为3种方式,分别为保健方式、医疗方式和综合方式,纳入的服务呈现出重医疗轻保健的状况;新农合妇幼卫生服务的补偿政策呈现出纳入项目增加,报销比例上升,逐步涉及保健项目的变化趋势。结论:预防保健的群体效益和社会效益要远高于个体医疗,随着筹资水平的提高,可以逐步纳入部分保健服务。     

Access and quality: does rural America lag behind?

Numerous state and federal programs and policies aim to improve rural health care. This study compares access to and quality of medical care in urban and rural areas from the perspective of physicians and patients, using a broad set of indicators taken from the 2000-2001 Community Tracking Study (CTS) Physician and Household Surveys. Across most dimensions examined, access and quality in rural areas-even rural counties not adjacent to metropolitan areas-were either equivalent or superior to that provided in urban areas. However, rural residents have greater difficulty obtaining mental health services and generally face greater financial barriers to care.     

天津市宝坻区某镇居民卫生服务满意度基线调查分析——国家科技部十一五规划项目“全科型乡镇卫生院建设”项目

目的:了解农村居民对乡镇卫生院卫生服务的满意情况,为发展和提高农村卫生服务提供理论依据。方法:随机抽取587名口东镇居民,通过问卷调查形式,进行就医满意度调查,并对数据进行描述性分析。结果:本次调查结果显示,农村居民对于乡镇卫生院门诊服务的总体满意度为31.8%,各分类的满意度由高到低依次为:护士满意度(80.3%)、就医便捷程度(72.6%)、城镇居民医保报销情况(52.1%)、收费合理性(44.3%)、服务态度(35.3%)、解释交流(33.7%)、慢病防治知识告知(8.6%)、预防保健服务(8.5%)、药品齐全程度(5.3%)、就医设施和环境(4.8%)、医师技术(4.8%)。结论:满意度最低的五项为医师技术、就医设施和环境、药品齐全程度、慢病防治知识告知、预防保健服务,满意度均不足10%,提示乡镇卫生院应多渠道提高医师自身业务水平,不断提高卫生院预防保健职能,优化卫生院就医条件,增加药品种类,为居民提供更优质的卫生服务,以提高卫生院的整体满意度水平。     

新农合对农村老年人医疗服务利用的影响——基于高龄、低龄老人分析

运用中国营养与健康调查数据(CHNS),实证分析了新农合对农村高龄和低龄老年人医疗服务利用的影响,从老年人群年龄异质性的角度,对新农合的实施绩效进行了重新考察。研究发现,与新农合实施前的2000年相比,新农合全面普及的2011年农村低龄老年患者的就医率增加了9.45%,而高龄老人的就医率却下降了13.38%;计量模型表明,新农合显著增加了低龄老人的医疗服务利用水平和预防保健支出,但对高龄老人的影响不显著。这表明经济因素可能仍是我国农村高龄老人医疗可及性的制约因素,新农合政策提高农村最脆弱群体医疗可及性的作用不明显。因此,政府应继续完善农村医保政策,关注农村最脆弱群体,以增加对农村高龄老人患病时的经济保护。     

基层卫生机构绩效管理相关问题探讨

基层卫生机构是实现人人享有基本医疗卫生服务的重要组织保证,随着政府对基层卫生机构投入的加大,加强基层卫生机构管理、提高绩效,对保障城乡居民获得基本医疗卫生服务具有重要意义。本文就基层卫生机构绩效管理的相关问题,包括对绩效的正确理解、绩效管理操作以及绩效管理中应注意的问题等进行探讨,提出了可操作性的建议。     

Insurance + access not equal to health care: typology of barriers to health care access for low-income families

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers.     

会泽县卫生服务利用的公平性研究

目的了解会泽县新型农村合作医疗实施中,参合农民卫生服务利用的公平性,为制订合理的补偿方案提供依据。方法采用分层抽样的方法抽取2个乡镇,共调查农户1209户,计4646人。结果调查农民2周患病率为7.1%,2周患病就诊率为8.7%,均低于第三次全国卫生服务调查农村平均水平。2005年住院率为5.6%,高于全国平均水平(3.4%),不同乡镇和不同家庭经济收入农民门诊服务利用的差异不大,但住院服务存在统计学差异。住院率随收入增加而增高,需住院未住院比例随收入增加而降低。住院机构、次均住院费用和次均住院补偿费用在2个乡镇间有较大差异,而在不同经济收入间无明显差异。结论新型农村合作医疗实施中,应该注意提高卫生服务利用的公平性。     

Preventive services for rural and urban African American adults

BACKGROUND: Studies have shown that African Americans and rural patients receive fewer preventive services than other patients. OBJECTIVE: To compare the use of preventive services by African Americans in urban and rural settings to determine if race and rural residence were additive risks for not obtaining preventive services. METHODS: Three hundred African American patients seeking care in family practices in South Carolina were surveyed about preventive health care. RESULTS: Rural and urban African Americans were equally likely to know about preventive services and be up-to-date on receiving these services. In both practices, those with lower incomes were less likely to be up-to-date. Patients seen in the urban setting were more likely to receive counseling regarding exercise and smoking than those in the rural practice (87% vs 71%, P = .003). CONCLUSIONS: For both urban and rural African American patients with access to primary care physicians, preventive service use is high. The best predictor of poor compliance with preventive service recommendations was low income, suggesting that a lack of access to care is the primary reason why rural and African American populations do not receive adequate preventive health care.     

PREVENTIVE SOCIAL HEALTH PROGRAMS: ARE THEY AUSTRALIA’S ANSWER TO RISING HEALTH CARE COSTS IN RURAL COMMUNITIES?

ABSTRACT: Although we have good evidence to support the notion that early intervention, prevention and community education programs can mitigate the impact of preventable disease, expanded primary health care is also being promoted by Australian governments as a panacea for reducing growth in demand generally. While preventive programs do reduce acute demand, they may not do so to the extent that resources, currently allocated to the acute sector, can be substituted to provide the additional primary care services necessary to reduce acute demand permanently. These developments have particular relevance for rural and isolated communities where access to acute services is already very limited. What appears to be occurring, in rural South Australia at least, is that traditional acute services are being reduced and replaced with lower level care and social intervention programs. This is well and good, but eventually the acute care being provided in rural health units now will still need to be provided by other units elsewhere and probably at much higher cost to the system and to consumers. Where rural communities have previously managed much of their own acute service demand, they may now be forced to send patients to more distant centres for care but at much greater social and economic cost to individuals and the system.     

全方位参与 完善管理机制 是合作医疗可持续发展的关键

在合作医疗基本形成一个雏型后,要进一步办好合作医疗,使其保持持续发展,管理工作是关键。连续3年的上海市医学领先课题研究提示,只有调动三级医疗机构的积极性,调整三级合管会的功能,共同来参与合作医疗的管理,发挥各自的优势,才能保证合作医疗正常、平稳、持续地发展,为农村居民提供医疗、预防、保健、康复全方位的服务。     

Readiness for Medicaid Managed Care Reform Initiatives: A Profile of Rural Family Physicians

Medicaid managed care is now an important factor in the financing of rural health care delivery. The participation of rural family physicians in Medicaid managed care is vital for the rural poor to access health services. This study examined 855 family physicians practicing in nonmetropolitan counties across the United States to determine their readiness to participate in Medicaid managed care. Physicians were asked about their experience with prepaid programs and the factors that would influence their participation in such a program. A shortage of health care providers and low reimbursement rates were most frequently cited as barriers to successful implementation. Physicians who had participated in prepaid programs in the past but were no longer participating had the most negative opinions about the potential for Medicaid managed care programs to enhance care for the poor in their communities. Overall, physicians reported potential for the program to improve access and quality of care, but they also expressed reservations about the financial and administrative effects on their practices. These results reveal that negative attitudes were associated with prepaid programs that failed to meet expectations, but physicians also expressed an optimism about the potential to serve the poor within a managed care model.     

新型合作医疗对东营市农村居民门诊服务利用的影响研究

目的分析新型合作医疗对农村居民门诊卫生服务的影响，为完善新型合作医疗制度提供科学依据。方法采用分层整群随机抽样方法，在实施新型合作医疗前后分别对东营市居民进行入户访谈式问卷调查。结果实施新型合作医疗后农村居民的两周就诊率虽没有增加，但患者就诊流向发生改变，两周未就诊率则呈显著下降趋势，增加了居民卫生服务利用的公平性。结论新型合作医疗是农村患者就诊的有力保障。     

Optimization of preventive health care facility locations

Background  

Preventive health care programs can save lives and contribute to a better quality of life by diagnosing serious medical conditions early. The Preventive Health Care Facility Location (PHCFL) problem is to identify optimal locations for preventive health care facilities so as to maximize participation. When identifying locations for preventive health care facilities, we need to consider the characteristics of the preventive health care services. First, people should have more flexibility to select service locations. Second, each preventive health care facility needs to have a minimum number of clients in order to retain accreditation.