Equity, governance and financing after health care reform: lessons from Mexico

To determine, from the perspective of providers, community leaders and users of health services, equity, governance and health financing outcomes of the Mexican health system reform.Cross-sectional study oriented towards the qualitative analysis of financing, governance and equity indicators for the uninsured population. Taking into account feasibility, as well as political and technical criteria, six Mexican states were selected as study populations and a qualitative research was conducted during 2004-2006. Two hundred and forty in-depth interviews were applied, in all selected states, to 60 decision-makers, including medical and administrative personnel; 60 service providers at health centres; 60 representatives of civil organizations, including municipal representatives and, finally, 60 members of health committees and users of services at second and first levels of care units. The analysis of interviews was performed using ATLAS-Ti software. An outcome mapping of health reform was developed. For political actors, Mexican health system reform has not modified dependence on the central level; ignorance about reform strategies and lack of participation in the search for financial resources to finance health systems were evidenced. Also, in all states under study, community leaders and users of services reported the need to improve an effective accountability system at both municipal and state levels. Health strategies for equity, governance and financing do not have adequate mechanisms to promote participation from all social actors. Improving this situation is a very important goal in the Mexican health democratization process, in the context of health care reform. There are relevant positive and negative effects of the reform on equity, governance and financing in health. Special emphasis is placed on the analysis of lessons learned in Mexico and the usefulness of the main strengths and weaknesses, as relevant evidences for other middle-income countries which are designing, implementing and evaluating reform strategies in order to achieve equity in resource allocation, good levels of governance and a greater financial protection in health.     

The convergence of health care financing structures: empirical evidence from OECD-countries

The convergence/divergence of health care systems between countries is an interesting facet of the health care system research from a macroeconomic perspective. In this paper, we concentrate on an important dimension of every health care system, namely the convergence/divergence of health care financing (HCF). Based on data from 22 OECD countries in the time period 1970–2005, we use the public financing ratio (public financing in % of total HCF) and per capita public HCF as indicators for convergence. By applying different concepts of convergence, we find that HCF is converging. This conclusion also holds when we look at smaller subgroups of countries and shorter time periods. However, we find evidence that countries do not move towards a common mean and that the rate of convergence is decreasing over time.     

Clinical governance in primary care

The government's stated top priority for the NHS is the quality of care of patients and there now exists a new duty of quality on all those providing care, accompanied by a drive for greater accountability to the public of clinical decision making. The process which governs these initiatives is termed clinical governance.     

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.     

The quality of immunization data from routine primary health care reports: a case from Nepal

Reported high immunization coverage achieved in Nepal over the last ten years is expected to reduce child mortality in the country. The present study, carried out in hill district in mid-west Nepal, aimed to assess the quality of immunization data in Nepal. The number of children who received different vaccines during one year was obtained from three sources: 1) the Immunization REgister of three Primary Health Care Service Outlets (PHCSOs) where each immunized child is recorded; 2) monthly PHC Reports, which are based on the Immunization Register; 3) monthly DHO Reports, which are based on the above PHC Reports (the DHO reports are the source of official statistics). The number of children in the PHC Reports was higher than the number in the Immunization REgisters for all vaccines. The number of immunizations in the DHO Reports was higher than the number in the PHC Reports for BCG, DPT, and measles; the number was lower for poliomyelitis. The overall number of immunizations was higher in the DHO Reports than in the Immunization Registers, by 31% for BCG, 44% for DPT, 155% for polio, and 71% for measles. We conclude that the official report overestimates the immunization coverage in the district. The immunization programme, therefore, might not result in the expected reduction of morbidity and mortality despite the investment in the programme and reported high coverage.     

澳大利亚社区卫生服务筹资与补偿机制对我国的启示

分析澳大利亚社区卫生服务筹资与补偿机制对我国的启示，提出改革我国社区卫生服务筹资与补偿机制的政策建议：建立政府与市场相结合的多层次、多形式的社区卫生服务筹资体系，努力拓展社区卫生服务机构生存发展的空间。     

A subtle governance: 'soft' medical leadership in English primary care

In many countries governments are recruiting the medical profession into a more active, transparent regulation of clinical practice. Consequently the medical profession adapts the ways it regulates itself and its relationship to health system managers changes. This paper uses empirical research in English Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) to assess the value of Courpasson's concept of soft bureaucracy as a conceptualisation of these changes. Clinical governance in PCGs and PCTs displays important parallels with governance in soft bureaucracies, but the concept of soft bureaucracy requires modification to make it more applicable to general practice. In English primary care, governance over rank-and-file doctors is exercised by local professional leaders rather than general managers, harnessing their colleagues' perception of threats to professional autonomy and self-regulation rather than fears of competition as the means of 'soft coercion'.     

Effect of managed care and financing on practice constraints and career satisfaction in primary care

BACKGROUND: The shift away from third party insurers to risk-sharing arrangements affecting care management and clinicians could be the most fundamental change in the health care system. Analysis was undertaken to study how managed care, practice setting, and financial arrangements affect physicians' perceived impact on their practice. METHODS: Data were taken from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Survey instruments were completed by 7,146 primary care physicians in internal medicine (2,355), family practice (3,168), and pediatrics (1,623). The dependent variables are career satisfaction and perceived limitations and pressures on time spent with patients, clinical freedom, income, and continuity. To study the unique effect of financing and gatekeeping arrangements and practice setting, the dependent variables were regressed on gatekeeping, practice revenue, individual physician compensation, practice setting, specialty, age-group, sex, international medical graduate, board certification, and recent change in practice ownership. RESULTS: Total managed care revenue, or individual physician incentives, have no effect on career satisfaction and relatively limited effects on time pressure, income pressure, or patient continuity. In contrast, primary care gatekeeping has a highly significant adverse effect on the same outcome measures. After controlling for financial factors, demographic characteristics, and training differences, physicians in solo and 2-physician practices are significantly more likely to be dissatisfied with their medical career, more likely to report no clinical freedom, and more likely to feel income pressure than physicians in group practices, staff model HMOs, medical schools, or other settings. CONCLUSION: Physicians in solo and 2-physician practices were least satisfied with their careers and reported more constraints on their clinical freedom and income than physicians in other settings. Physicians in group practices or staff model HMOs are more likely to report time pressure than physicians in solo or 2-physician practices. Family practice falls between internal medicine (less satisfied, more practice constraints) and pediatrics (more satisfied, fewer practice constraints).     

Emergency room use and access to primary care: evidence from Houston, Texas

To cope with the rising number of uninsured, communities around the country are pursuing a variety of strategies to expand local health care safety nets. One measure that has been suggested to evaluate what is working is primary care-related emergency department (ED) visits. In this paper, we evaluate the applicability of this measure as an access indicator by examining its correlation with other indicators of medical under-service. We obtained ED visit data from safety net hospitals in Houston, Texas and applied the New York University ED Algorithm to estimate the rate of visits that were primary care-related. We then examined at the ZIP code level the correlation of primary care-related ED visits per 1,000 population with the federal government's Index of Medical Underservice (IMU), the poverty rate, and the uninsurance rate. Primary care-related ED visits were found to be weakly correlated with the IMU and strongly correlated with the rate of uninsurance and poverty. These findings suggest that the combination of this indicator with other measures of access could be used to monitor and evaluate local initiatives designed to expand care and coverage to the medically underserved.     

Organization and financing of British primary care groups and trusts: observations through the prism of US managed care

There are many parallels between the UK's new primary care commissioning organizations and the managed care organizations and integrated delivery systems that have evolved in the USA over the last three decades. Those building primary care groups and trusts (PCG/Ts) can learn from the American experience with health maintenance organizations and other similar entities. These lessons should also be relevant to those in other countries interested in establishing innovative primary care led organizations within the broader structure of a socialized health care system. Following an overview of US managed care and an update of the progress of the UK's PCG/Ts, we go on to suggest how new consortia of PCG/Ts might be developed and how budgets and provider incentives could be structured. This international comparison suggests that the resources needed to support the development of effective PCG/Ts will be considerable, as will the need to maintain organizational flexibility. If primary care organizations are to thrive, it will be essential to develop truly integrated budgets for primary and secondary care.     

Mental health patients in primary health care services in Nepal

Patients attending two primary care settings in Nepal (a village health post and a district hospital outpatient department) were screened for psychiatric morbidity using the Self Reporting Questionnaire. Approximately one-quarter of all patients screened were found to have psychiatric morbidity. Women presenting were found to have higher frequency of "psychiatric caseness" than men. All these psychiatric patients presented with physical complaints, none with psychological, and the most common physical symptoms presented were abdominal pain, headache and cough. Health worker recognition of these cases was 29% in the health post and 0% in the hospital. Conclusions are drawn regarding the need for sufficient and relevant psychiatric teaching in health worker curriculae.     

Community-oriented primary care: a path to community development

Although community development and social change are not explicit goals of community-oriented primary care (COPC), they are implicit in COPC's emphasis on community organization and local participation with health professionals in the assessment of health problems. These goals are also implicit in the shared understanding of health problems' social, physical, and economic causes and in the design of COPC interventions. In the mid-1960s, a community health center in the Mississippi Delta created programs designed to move beyond narrowly focused disease-specific interventions and address some of the root causes of community morbidity and mortality. Drawing on the skills of the community itself, a selfsustaining process of health-related social change was initiated. A key program involved the provision of educational opportunities.     

Community governance in primary health care: towards an international Ideal Type

Against a global background of increased resource management responsibilities for primary health care agencies, general medical practices, in particular, are increasingly being required to demonstrate the legitimacy of their decision making in market oriented environments. In this context a scoping review explores the potential utility for health managers in primary health care of community governance as a policy concept. The review of recent research suggests that applied learning from international health systems with enhanced approaches to public and patient involvement may contribute to meeting this requirement. Such approaches often characterise local health systems in Latin America and North West Europe where innovative models are beginning to respond effectively to the growing demands on general practice. The study design draws on documentary and secondary data analyses to identify common components of community governance from the countries in these regions, supplemented by other relevant international studies and sources where appropriate. Within a comprehensive framework of collaborative governance the components are aggregated in an Ideal Type format to provide a point of reference for possible adaptation and transferable learning across market oriented health systems. Each component is illustrated with international exemplars from recent organisational practices in primary health care. The application of community governance is considered for the particular contexts of GP led Clinical Commissioning Groups in England and Primary Health Networks in Australia. Some components of the Ideal Type possess potentially powerful negative as well as positive motivational effects, with PPI at practice levels sometimes hindering the development of effective local governance. This highlights the importance of careful and competent management of the growing resources attributed to primary health care agencies, which possess an increasingly diverse range of non‐governmental status. Future policy and research priorities are outlined. Copyright © 2016 John Wiley & Sons, Ltd.     

Latent class models for use of primary care: evidence from a British panel

This paper models access to and utilisation of primary care using data from the British Household Panel Survey for the period 1991-2001. A latent class panel data framework is adopted to model individual unobserved heterogeneity in a flexible way. Accounting for the panel structure of the data leads to a substantial improvement in fit, and permits the identification of latent classes of users of health care. Analysis by gender shows that men and women respond differently to some factors, in particular, to age and income. There is evidence of a positive impact of income on the probability of seeking primary care. This effect is especially significant in the case of women. For both genders, the marginal effect of income on the propensity to visit a GP is greater for individuals who are less likely to seek primary care. A latent class aggregated count data model for the number of GP visits classifies individuals in three latent classes and shows a positive income effect particularly amongst those with lower levels of utilisation.     

Health reform and primary care capacity: evidence from Houston/Harris County, Texas

This study estimated the possible surge in demand for primary care among the low-income population in Houston/Harris County under the Patient Protection and Affordable Care Act, and related it to existing supply by safety-net providers. A model of the demand for primary care visits was developed based on California Health Interview Survey data and applied to the Houston/Harris County population. The current supply of primary care visits by safety-net providers was determined by a local survey. Comparisons indicate that safety-net providers in Houston/Harris County are currently meeting about 30% of the demand for primary care visits by the low-income population, and the rest are either met by private practice physicians or are unmet. Demand for primary care by this population is projected to increase by 30% under health reform leading to a drop in demand met by safety-net providers to less than 25%.     

Determinants of parental reports of children's illnesses: empirical evidence from Nepal

Household surveys from the developing world consistently record a generally low level of illness reporting, but the evidence that substantial differences exist in illness reporting between income groups is scanty. In contrast, a huge gap in illness reporting exists between rich and poor countries. Medical anthropologists have highlighted the differential illness perception across income groups but little is known as to what extent economic variables do determine one's illness decision. In this paper, discrete choice theory is used to explain why some parents choose to report their children's illnesses more often than others in Nepal. An empirical model is developed that depicts illness-reporting decisions as a function of inter alia, price and income. Data are drawn from Phase I of the Nepal Living Standards Survey. The results suggest that income as well as the price that parents expect to pay on treatment of their children's non-chronic ailments determine their decision to report an illness, when controlling for other variables (price responsiveness =−1.16; income responsiveness=0.23; p-value=0.00). This behaviour is theoretically consistent as parents weigh the opportunity costs of their decision (here, choosing to report an illness). Its implications are broader and raise other questions, e.g., Can we explain the difference in illness-perception rates between rich and poor countries that have different mechanisms to finance health care?