Participation in health care priority-setting through the eyes of the participants

OBJECTIVES: The literature on participation in priority-setting has three key gaps: it focuses on techniques for obtaining public input into priority-setting that are consultative mechanisms and do not involve the public directly in decision-making; it focuses primarily on the public's role in priority-setting, not on all potential participants; and the range of roles that various participants play in a group making priority decisions has not been described. To begin addressing these gaps, we interviewed individuals who participated on two priority-setting committees to identify key insights from participants about participation. METHODS: A qualitative study consisting of interviews with decision-makers, including patients and members of the public. RESULTS: Members of the public can contribute directly to important aspects of priority-setting. The participants described six specific priority-setting roles: committee chair, administrator, medical specialist, medical generalist, public representative and patient representative. They also described the contributions of each role to priority-setting. CONCLUSIONS: Using the insights from decision-makers, we have described lessons related to direct involvement of members of the public and patients in priority-setting, and have identified six roles and the contributions of each role.     

Sexual and reproductive health: challenges for priority-setting in Ghana's health reforms

Many countries are undertaking widespread structural change of their health sectors. There is mounting concern that priority-setting mechanisms used in planning the reforms are not suited to recognizing or taking account of the needs and priorities of sexual and reproductive health (SRH) services. The main aim of this research was to assess the sensitivity of the priority-setting tools and mechanisms used in the development of the health sector reforms in Ghana, to the needs and priorities of SRH services, and to consider how priority-setting mechanisms could be improved. We conclude that priority-setting tools in Ghana's reform process were rudimentary, and SRH donors and advocates were little involved. While it is tempting for a strong programme like Ghana's SRH programme to remain independent, we argue that closer involvement in system-wide reforms is a preferable long-term objective. Clearly, SRH priorities need safeguarding within a systems approach and we suggest a number of ways in which this can be achieved. Most importantly, the SRH community, in collaboration with the wider development community, needs to challenge current priority-setting mechanisms and the long-held view that traditional disease-ranking and cost-effectiveness measures are necessarily the best, most accurate way to measure health priorities. Traditional priority-setting tools do not adequately reflect the long-term benefits of preventive interventions such as family planning, and are therefore not an adequate reflection of holistic health sector planning needs. In response to this, there needs to be greater commitment from the international development and research communities to: (1) support collaboration between economists and reproductive health specialists to develop better measures for the effectiveness and impact of SRH services; and (2) in the interim, accept proxies for priority-setting which may include small-scale, qualitative research data combined with priorities identified by SRH specialists. To achieve this, the priority-setting processes need to become more inclusive and SRH specialists need to be proactive in their engagement with health sector decision-makers.     

Rationing health care: an exploration

Rationing involves a failure to offer care, or the denial of care, from which patients would benefit. Rationing involves definition of efficiency (benefit) and equity (fairness) allocation criteria and a recognition of a trade-off between the two. However, accountability for rationing choices also requires careful governance of the agents of society, doctors, who judge the health needs of competing patients. An integrated rationing system requires management of patient access criteria, the knowledge base which informs practice and clinical practices.     

Professional values in health care

All professionals subscribe to certain values and have concerns about their freedom and autonomy. When professionals work in large and complex organisations such as hospitals, differences in the values of various groups are reflected in disagreement. Tony Kennerley argues that the manager's task is to create harmony out of such dissonance.     

Professional autonomy and managed care in Dutch health centres: stakeholders' perceptions of a strategic option

The on-going reforms of the Dutch health care systems call for the introduction of managed care elements. Health centres in the Netherlands already bear some resemblance to health maintenance organizations in the USA. However, managed care challenges provider autonomy, and the strategic development of managed care plans may be hampered by providers' perceptions. We draw a distinction between managed care within an insurance arrangement and managed care as a package of methods. Both options are evaluated as suitable for Dutch health centres, though with differences in terms of strategic logic and cultural fit. Lastly, some general conditions are formulated that should be considered before care management processes can be implemented. These include: specify clear objectives for introduction of managed care; strengthen corporate culture; develop internal motivation for change; develop a practice criterion with health centre professionals; reduce workloads in order to provide development time; and, promote better cooperation between general practitioners and specialists.     

Generalized cost-effectiveness analysis for national-level priority-setting in the health sector

Cost-effectiveness analysis (CEA) is potentially an important aid to public health decision-making but, with some notable exceptions, its use and impact at the level of individual countries is limited. A number of potential reasons may account for this, among them technical shortcomings associated with the generation of current economic evidence, political expediency, social preferences and systemic barriers to implementation. As a form of sectoral CEA, Generalized CEA sets out to overcome a number of these barriers to the appropriate use of cost-effectiveness information at the regional and country level. Its application via WHO-CHOICE provides a new economic evidence base, as well as underlying methodological developments, concerning the cost-effectiveness of a range of health interventions for leading causes of, and risk factors for, disease.     

Task shifting in maternal and child health care: an evidence brief for Uganda

THE PROBLEM: There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers ("task shifting") is one strategy to address the shortage and maldistribution of more specialized health professionals. POLICY OPTIONS: (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. IMPLEMENTATION STRATEGIES: A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers' knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.     

Health care financing in Uganda: the role of social health insurance

PURPOSE: The purpose of this article is to explore the feasibility of introducing a social health insurance (SHI) scheme in Uganda from the perspectives of a targeted population of respondents in Kampala, Uganda. DESIGN/METHODOLOGY/APPROACH: Out of 100 questionnaires distributed to a random sample of Ugandans, 74 were returned, yielding a 74 percent response rate. FINDINGS: Results show that all Ugandans surveyed support the introduction of SHI. Some are willing to contribute financially and most believe that the Ugandan government should make this benefit available to all Ugandans. While there is a great deal of support for introducing SHI, several respondents noted that cost sharing, in whatever form taken, is burdensome on people with lower incomes and has disastrous consequences for the delivery and utilization of health services among the poor. ORIGINALITY/VALUE: A larger study exploring Ugandans' perspectives may provide valuable information on how Africans can begin to design a workable health financing structure to promote better access to health care for the most vulnerable groups in society.     

Benchmarking graduate health administration programs: stakeholders' perceptions

The purpose of this study was to identify and compare among key stakeholders the factors in graduate health care administration education that are perceived to be important for ranking, or benchmarking, based on the opinions of those stakeholders, i.e., program directors, faculty, graduate students, and accrediting agency commissioners. We used an original survey to obtain stakeholders' perceptions and opinions about important process and outcome measures. We sent it to all ACEHSA-accredited graduate health care administration programs in the United States, Canada, and Puerto Rico; to full-time faculty members in each program; to three current graduate students in each program, and to all ACEHSA commissioners. We performed frequency of responses, Analysis of Variances (ANOVA) tests, and Dunnett T3 tests. A response rate of 32 percent (n = 156) was achieved for all stakeholders. A total of 67 percent of all respondents reported that benchmarking graduate health care administration programs was important. The study results revealed a significant difference between populations on the importance of evaluating certain process and outcome measures related to curriculum, research, student characteristics, and resources. However, most of the stakeholders reported that curriculum, faculty, and graduate student performance were the key quality indicators of a program. The results of this study provide preliminary information for health care administration programs to begin to develop an educational benchmarking effort.     

Criteria for choosing health care facilities for prenatal care in Pelotas, RS, Brazil

OBJECTIVE: To describe the prenatal care delivered to a representative sample of mothers, identifying the health care facility they attended and to explore the reasons that led them to choose that specific health facility. METHOD: A cross-sectional study was conducted at four maternity hospitals in Pelotas, in Southern Brazil, from March to April 1997. A total of 401 mothers were interviewed at the hospital, immediately after delivery. RESULTS: The majority of mothers (51%) were followed up at a primary health care facility (PHCF). The main reported reason for choosing a PHCF was its geographic accessibility (46.8%). For 85% of the mothers, the nearest health service was a PHCF. However, 52.2% of them did not attend the consultations at this setting mainly because of a supposed low quality care (37.4%). Except for immunization with tetanus toxoids, all other usual prenatal care procedures recommended by the local health ministry, including promotion of breastfeeding, were performed less frequently at the PHCF than in other health care settings. CONCLUSION: Given the high coverage of the public prenatal care program, efforts should be made to improve the quality of care delivered to pregnant women, mainly by encouraging health professionals, especially doctors, to follow the established guidelines.     

Private and public health care in rural areas of Uganda

Background  

In many low and middle income countries, the private sector is increasingly becoming an important source of health care, filling gaps where no or little public health care is available. However, knowledge on the private sector providers is limited The objective of this study was to determine the type and number of different types of health care providers, and the quality, cost and utilization of care delivered by those providers in rural Uganda.     

Core values in health care reform: a communitarian approach

Controlling health care costs should allow the nation to provide more health services and higher quality care to more people. The authors are concerned, however, that many of the reform efforts will unwittingly undermine the culture of care in their pursuit of savings and access. This article is a plea to maintain the core moral values and the social and institutional commitments that are essential in the delivery of care, so that the health care community is not turned into a health industry. The authors' communitarian approach aims to preserve the balance between individual rights and social responsibilities, the moral integrity of a caring society, and the unique character of mutual trust between patients and health care personnel. They advocate an orientation toward preventing disease and promoting health, an imperative of reforming the violent, reckless, and costly aspects of American society, and a moral justification for cutting administrative waste, defensive medicine, and excessive profits rather than rationing beneficial and humane health services.     

Learning to care: a focus for values in health and environmental education

Health and environmental education seek to address the livingconditions and lifestyle choices that lead to health and environmentalproblems by motivating and teaching students how to participatein the reconstruction of themselves and society in accordancewith ecological values and the democratic values of social andeconomic justice. While an ethic of care unites health and environmentaleducation in this endeavour, liberal and conservative educationalpractices in the area of values education are dominated by discoursesof values relativity and neutrality. This paper seeks to providea case for teachers adopting a committed stance in teachingyoung people an ethic of care so that they may participate inthe personal and social changes needed to advance the transitiontowards a healthy and sustainable world. In particular, it drawsupon insights from the literature of environmental values education,which is characterized by intense debates between those of liberaland committed persuasions, to explore the ethical and pedagogicalissues involved in teaching for an ethic of care in both healthand environmental education.     

Criteria for the management of low back pain in health care workers

Low back pain represents one of the most frequent health problems in several working populations and is an important problem for occupation health doctors. In fact, these professionals are often required to face with the specific management of this condition, also by participating with other professionals into the implementation of organizational and structural measures. This contribute describes a variety of interventions aimed at treating the syndrome and recovering the working ability of the patient-worker, including the initial clinical evaluation, the assessment of the casual relationship between work and the syndrome, the treatment, the formulation of proposals to modify the worker's physical and working activity, the ongoing heath surveillance and a more in-depth clinical and instrumental evaluation, including surgical treatment.