Health care in rural areas

In India, although the health care system infrastructure is extensive, the people often regard government facilities as family planning (FP) centers instead of primary health care centers. This problem has been compounded by the separation of health care and FP at all stages, even down to the storage of the same medication in two different locations depending upon whether it is to be used for "health" or for "FP." In rural areas where the government centers are particularly desolate, the community has chosen to erect its own health care system of private practitioners of all sorts and qualifications. Even in rural areas where a comprehensive health service is provided, with each household visited regularly by health workers, and where this service has resulted in a lowering of the crude death rate from 14.6 to 7 and the maternal mortality rate from 4.7 to 0.5/1000, people depend upon practitioners of various types. Upon analysis, it was discovered that the reason for using this multiplicity of practitioners had nothing to do with the level of satisfaction with the government service or with the accessibility of the services. Rather, when ill, the people make a diagnosis and then go to the proper place for treatment. If, for instance, they believe their malady was caused by the evil eye, they consult a magico-religious practitioner. These various types of practitioners flourish in areas with the best primary health care because they fulfill a need not met by the primary health care staff. If government agencies work with the local practitioners and afford them the proper respect, their skills can be upgraded in selected areas and the whole community will benefit.     

Health care in China: the role of non-government providers

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.     

Of mud and alligators

Each year Dr Mahler, Director-General of the World Health Organization,presents a report to member country delegates at the World HealthAssembly. In his address this year, he likened WHO's attemptsto promote primary health care (PHC) and Health for All by theYear 2000 to being in a swamp, ‘up to our necks in verbalmud, fighting all sorts of conceptual alligators’. Yetthe aim is to clear the swamp. We reproduce here most of thataddress, not only for its lively images, but also because init Dr Mahler takes on some of the conceptual and other criticismsof PHC, recapitulates what it is all about, casts a dear eyeover how countries are faring in their implementation of PHC,and outlines some suggested areas for action in the coming years.Going back to first principles, he argues that PHC starts withpeople, their health problems, and their active involvementin solving those problems. It is that active involvement thatdistinguishes PHC from past health policies. It is not by chancethat the very first element of PHC is educating people and communitieson health matters, because for people to be intelligently involvedin caring for their own health, they have to understand whatleads to health and what endangers it. A crucial point is emphasized-thatit is people themselves who decide what kind of care is requiredand not outsiders. In reviewing action programmes for PHC, DrMahler emphasizes the need for good organization and management,and calls for efforts to be concentrated on building up districtinfrastructures, with defined targets to galvanize people intoaction. He makes a number of suggestions for setting realistictargets and deciding what appropriate technologies exist thatcan be appropriately applied. The speech is a useful policypointer on the road to Health for All by the Year 2000.     

Becoming an information master: using "medical poetry" to remove the inequities in health care delivery

In response to the spiraling costs, the US populace, for now, has chosen to ration health care by choosing who can receive it rather than what services are provided. Changing this approach will require an organized national policy and will be difficult. Clinicians must accept that providing minimally beneficial but not absolutely necessary care to their patients increases cost without significantly improving quality, and results in more people who lack adequate health care. The public must accept that exclusively focusing health care decisions on individuals places patients in conflict with their community, their family, and, eventually, themselves. Effectively using valid Patient-Oriented Evidence that Matters (POEMs) will give family physicians the tools necessary to improve the value of health care services. Family physicians are in the unique position to guide the necessary changes in health care delivery to resolve these conflicts and to be leaders in this process.     

Community involvement in health policy; socio-structural and dynamic aspects of health beliefs

The notion of community involvement in health, as in fact in schemes of community welfare generally, has found wide acceptance in all kinds of political regimes and particularly in the Third World countries. Such involvement is expected not only to be cost-effective but, more importantly, the best way of providing comprehensive solutions to public health problems. More than 50 years of experience with schemes of community participation in India, however, show that the enthusiasm of the people generally tends to wane after a short period of time. Nevertheless, efforts at community involvement in health continue to be made. Governmental and non-governmental organizations and UN agencies, notably WHO, have been active in promoting the concept. The 1978 Alma Ata declaration on primary health care strongly emphasized the right and duty of people to plan and implement health care programmes. Even so, many operational problems remain and these are perhaps related partly to a lack of conceptual clarity. Ideally, community involvement should mean that the initiatives come from the people and the government and other agencies provide assistance. In reality, however, this rarely is so. The best that may be expected is that people will come forward voluntarily to participate in public health programmes. Generally, however, their co-operation has to be sought and they have to be motivated to participate in health schemes. Involvement could also be brought about through coercive measures but there is little support for such an approach, though many health programmes (such as that of small pox vaccination) have been known to have depended upon compliance for their success.(ABSTRACT TRUNCATED AT 250 WORDS)     

Why prevention can increase health-care spending

This article examines the impact of disease prevention on health-care spending. The relationship between these two variables is more complex than what, at first glance, appears to be the case. Health-care spending would be reduced if more effective means could be found to prevent health problems that are expensive to treat but are generally not fatal, such as dementia, infectious diseases and accidents. The major focus here is on interventions designed to persuade people to quit smoking. Savings on health-care spending in early years after people stop smoking are counter-balanced (often exceeded) by higher spending at a later time. In addition, when people stop smoking there is a significant negative impact on government finances from the double effect of lost tax revenues combined with increased spending on pension payments. Arguments in favour of policies designed to prevent fatal disease, such as by reducing the prevalence of smoking, should be based on improvements to population health rather than on misleading claims that this will reduce spending on health care.     

Health care in China after Mao.

This article summarizes observations made by the author during a recent trip to China and compares these views to those of other observers over the past decade. The discussion is undoubtedly influenced by the Chinese tendency to speak in terms of the ideal rather than what exists. It was often difficult to sort out "what is" from "what ought to be," even though our hosts appeared very candid, and, for the most part, our observations confirmed what we were told. Interpretation of observations is also colored by China's new surge of leadership, which causes health care policies to be in a continual state of transition. This makes any paper on contemporary Chinese health care somewhat outdated by the time it is published. However, there appear to be larger concerns reflecting basic Chinese attitudes toward health care that have evolved during the post "Liberation" period and which underlie day-to-day policy fluctuations. The analysis which follows attempts to isolate basic trends from more transitory events to clarify the the essential aspects of Chinese health care policy.     

QALYs and ethics: A health economist's perspective

Objectors on ethical grounds to the use of QALYs in priority-setting in public health care systems are here categorised as (1) those who reject all collective priority-setting as unethical; (2) those who accept the need for collective priority-setting but believe that it is contrary to medical ethics; (3) those who accept the need for collective priority-setting and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it on other ethical grounds; and (4) those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. It is argued that the first two groups of objectors are simply wrong, if distributive justice is a proper ethical concern in this context. The third group is of more interest, as this group appears to believe that QALYs are unethical because it is unethical to regard QALY maximisation as the sole objective of the health care system. This paper argues that QALYs are relevant to a much wider range of objectives than QALY maximisation, and that they can accommodate a wide variety of health dimensions and sources of valuation. They can also accommodate the differential weighting of benefits according to who gets them, so they do not commit their users to any particular notion of distributive justice. What they do commit their users to is the notion that the health of people is a central concept in priority-setting, and that it is desirable, for reasons of accountability, to have the bases for such priority-setting made as precise and explicit as possible. The fourth group of objectors needs to acknowledge that there is no perfect system on offer, and since priority-setting does and will proceed willy-nilly we cannot wait until there is. It would be more constructive to set up the desiderata that a priority-setting system should ideally fulfil, and then appraise all feasible alternatives (including the status quo) even-handedly by those criteria. None will be perfect, but this author predicts that QALYs would emerge from such an appraisal with a significant role to play.     

Taking charge--strategies for self-empowered health behavior among older people.

RECENT campaigns aimed at increasing awareness of health issues amongst older people have contributed much to the debates about health education and health promotion. Unfortunately though, publicity campaigns fail to address the very practical aspects of how we might help older people develop self-empowered health behaviour. This article considers firstly what it means to be poor and powerless and describes seven key factors which facilitate self-empowered health behaviour. These are then related to an innovative health project being developed with older people in Stoke-on-Trent, funded jointly by the Beth Johnson Foundation and the EEC under its Second Poverty Programme.     

Is decentralisation the real solution? A three country study

Decentralisation in the health care sector has been perceived in these last years as a means to revamp the performance of health care systems. Many European countries have undergone this process of delegating funding and/or management responsibilities to sub-layers of government. However, there has also been a recentralisation of health care systems in Nordic states, which typically had a highly decentralised model of service provision and funding. Three country cases will be analysed (Italy, Spain and Norway) and light will be shed on some possible difficulties that Italy and Spain might experience, given their present health decentralised structure. Moreover, there will be an analysis of the reasons that led to recentralisation of health care in Norway. The scope is to make people aware that decentralisation per se is not always successful. The three country cases highlight possible drawbacks that can arise from decentralisation.     

Beliefs about informal payments in Albania

Informal payments for health care are a growing concern in Albania and other transitional economy countries. Recent international studies have shown that informal payments can have negative effects on health care access, equity and health status by causing people to forgo or delay seeking care, or sell assets to pay for care. Many countries are putting in place reforms meant to reduce informal payments. In order to be successful, such policies need to consider people's attitudes and beliefs about the practice. This study collected data from 222 citizens in Albania regarding intentions, past behaviours, attitudes and beliefs about informal payments. Comparing people who intend to make informal payments with people who do not intend to make payments, the study found differences in attitudes as well as beliefs about the consequences of making informal payments, in perceptions about what others think and in control beliefs, but no difference in moral beliefs or demographic characteristics. People who intend to make informal payments the next time they seek care are more likely to believe they will get faster and better quality care than non-intenders, but also think they must pay to receive any care at all. People who do not intend to make informal payments are more likely to report that they have connections with medical personnel, which may be substituting for informal payments. The study has implications for educational campaigns accompanying policy reforms. Campaigns which focus on anti-corruption messages are unlikely to be effective, as moral beliefs do not appear to influence intention.     

Making culture a forethought. What to do when strategy meets organizational culture

Organizational culture is a key ingredient in successfully managing monumental strategic change initiatives. Those who are successful in managing change are actively integrating organizational culture into their total planning process. Organizational cultures should be a forethought in the management of the change process. Managers should give the same care and thoroughness to culture that they allot to the other major aspects of a plan. The culture of any organization in the midst of rapid change will not tolerate an information vacuum. People affected by change want to be able to ask questions and be heard. Communication should be interactive. Create opportunities that allow people at all levels of the organization to close the past. Without closure, some of the best people may feel that the organization has betrayed them. Creating a process that allows people to work through the change and motivating people to reinvent their approach and role in the new ways of doing things is what healthcare leadership in the 1990s is all about. It is part of the critical skill set that is necessary to lead Catholic-sponsored health services into the future.     

国内关于药事服务费的争议

新医改方案提出,设立药事服务费等多种方式逐步改革或取消药品加成政策。但是,国内对药事服务费存在很多争议。本文综述了国内关于药事服务费概念、现阶段是否应该征收、如何征收、征收面临难题,征收条件等方面的争议。由此,本文认为,我国征收药事服务费应加大政府投入,将其纳入医疗保险报销范围,进行系统推进。     

Toward a health care financing strategy for the nation. Report of the National Health Policy Seminar.

All people in the United States have a need for access to comprehensive high quality health care. Such need is so universal and fundamental, not only to personal health, but also to equitable pursuit of all opportunity in a modern and just society, that it is viewed increasingly in the context of rights. Although the current array of health financing programs--Medicare, Medicaid, employer-based medical care insurance benefits, private medical care insurance, and other current insurance methods--have major accomplishments to their credit in providing access to care, the United States falls short in guaranteeing that conceptual right. The result is that 35 to 40 million people in the United States have no insurance coverage at all for medical care expenses, and an unknown number of people have coverage that is grossly inadequate. In addition, our current medical care system is characterized by: significant barriers to equitable access to care, apart from lack of coverage of the direct costs; major deficiencies in services for rehabilitation, long-term care, and home care; extreme variablity in the utilization and quality of care. We also must acknowledge failures in fundamental programs that directly affect the health of our people, such as health manpower, housing, education, and protection against occupational and environmental hazards. However, these matters are outside the purview of this statement. We propose a program, under the leadership of the federal government, with state and local government and the private sector having significant roles to play, that will respond to these shortcomings in our health care system. The program would finance health services comprehensively and equitably, minimize duplication, inefficiency, and the uneven quality of care, and would emphasize health promotion and disease prevention.     

Algorithms in medicine.

The ever rising costs of health care in Western countries necessitate some form of cost control. Restrictions can be and will be imposed externally by, for instance, the government. These measures will probably lead to a decrease in quality of health care and the profession should therefore seek ways to prevent outside interference by developing an internal means of cost control. On short terms a form of internal control with preservation of the quality of care would be the introduction and widespread use of algorithms, restricting the use of useless and unnecessary tests and therapies. For long term results education must take on new tasks leading to a better understanding of costs an benefits of medical activities. The development of algorithms is hindered by the lack of common consensus of optimal care, the lack of relevant data and the inefficient way data are managed. When introduced the algorithm, especially when compulsory, will engender much resistance and unhappily, ways must be found to overcome them by sanctions. The profession must realise that if they do not do anything it will be done for them.     

Japanese occupational therapy in community mental health and telehealth

Help for people with mental health problems in Japan has traditionally centred on inpatient medical care. In a revision of the Mental Health Welfare Law planned for 2001, responsibility for the support of people with mental health problems will be transferred from central government to local government. Furthermore, local government will, in turn, delegate administrative tasks to a 'community life support centre'. We believe that such a centre could be linked to a university with a telehealth network. Connection to the network could benefit people with mental health problems living at home. We also believe that occupational therapists are ideally positioned to play a significant role in community life support centres. With the expected sustained growth in Japanese occupational therapy, it could become a key profession in the rehabilitation of people with mental health problems.     

美国卫生费用上涨和控制及对我国的启示

长期以来,美国卫生费用总量与人均水平居世界首位并保持了较高的增长速度,对于该国政治、经济、社会与人民生活等产生了严重影响。美国卫生费用居高不下的主要原因包括对重点人群和疾病的费用控制措施不力、卫生体制过于复杂导致管理成本过高、人力成本和服务价格过高等。在过去40多年里,虽然美国根据限制、整合和竞争等原则采取了诸多费用控制措施,但收效不大。借鉴美国的相关经验教训并结合我国实际情况,本文的主要建议包括:(1)重视完善的卫生体制在费用控制中的重要作用;(2)在医药卫生体制改革中不宜过分提倡市场化;(3)政府在卫生费用控制中应发挥关键性作用并充分发挥医疗保险机构和医疗服务提供者的作用;(4)在支付方式改革上应重视归纳总结与宏观管理,避免支付方式复杂化;(5)对于医疗机构的横向合并应持审慎态度。     

Vietnam during economic transition: a tracer study of health service access and affordability.

For many decades, Vietnam had a well-structured public health service with extensive population coverage, with free care at government health facilities until 1989. Since then the country has been going through economic transition, including major changes to the health system. These include the reduction of financial support to public facilities and the introduction of user charges. Concern has been growing about the effect of these changes on access and affordability of health care, particularly for poor families. Using data from the Vietnam National Health Survey conducted in 2001-2002, the authors conducted a tracer study of people with diarrheal illness to examine equity in access to and use of health care and the financial burdens placed on patients in seeking care. The study found that children, the elderly, and the poorly educated were more likely to suffer from diarrhea; poor people often did not seek any care regardless of severity of illness, largely because they could not afford it. The opportunity cost due to lost income was also much greater for poor families. Several new policies have been developed in Vietnam to improve access to basic health care for the poor. However, the effects of such policies require close monitoring and remain to be evaluated.     

Insurability and the HIV epidemic: ethical issues in underwriting

The HIV epidemic has focused criticism on standard underwriting practices that exclude people with AIDS or at high risk for it from insurance coverage. Insurers have denied the charge that these practices are unfair, claiming instead that whatever is actuarially fair is fair or just. This defense will not work unless we assume that individuals are entitled to gain advantages and deserve losses merely as a result of their health status. That assumption is highly controversial at the level of theory and is inconsistent with many of our moral beliefs and practices, including our insurance practices. We should reject the insurers' argument. Justice in health care requires that we protect equality of opportunity, and that implies sharing the burden of protecting people against health risks. In a just healthcare system, whether mixed or purely public, the insurance scheme is in systematic terms actuarially unfair, for its overall social function must be to guarantee access to appropriate care. This does not mean that in our system insurers are ignoring their obligation to provide access to coverage. The obligation to assure access is primarily a social one, and the failures of access in our system are the result of public failures to meet those obligations. In a just but mixed system, there would be an explicit division of responsibility among public and private insurance schemes. In our mixed but unjust system, both legislators and insurers cynically pretend that the uninsured are the responsibility of the other. The attempt to treat actuarial fairness as a moral notion thus disguises what is really at issue, namely, the risk to insurers of adverse selection and the economic advantages of standard underwriting practices. Standard underwriting practices will be fair only if they are part of a just system, not if they simply are actuarially fair. The failure of the argument from actuarial fairness means that we must face an issue private insurers had hoped to avoid if we are to defend standard underwriting practices at all. In view of the clear risk that a mixed system will fail to assure access to care, the burden falls on defenders of a mixed system. They must show us that its social benefits outweigh its social costs, and that it is possible to have a mixed system that is not only just, but also is superior to a compulsory, universal insurance scheme.