Health indicators and the organization of health care systems in western Europe.

OBJECTIVES. This study investigated the association between health care systems and health indicators in developed countries. METHODS. Cross-national comparisons were conducted with regression analysis between 17 Western European countries with two types of health care systems: national health services and social security systems. RESULTS. Health care expenditures were inversely correlated to potential years of life lost to females and to infant mortality rates; they were positively correlated to life expectancy for females. Regression models predicted that countries with national health services systems would have lower infant mortality rates at similar levels of gross domestic product (GDP) and health care expenditures. Finally, increases in health care expenditures would decrease the ratio of observed to predicted infant mortality rates according to GDP; this decrease would be greater in countries with national health services than in those with social security systems. The model predicted this difference to be about 13% at average levels of health expenditures. CONCLUSIONS. National health services seem to be more efficient at producing lower infant mortality rates than social security systems in Western European countries.     

Monitoring of primary health care services: an example from western Uganda

Results from baseline and follow-up surveys of the Basic Health Services Program in Kabarole District, Western Uganda carried out in 1989 and 1991 are presented. Indicators in relation to management capability, infrastructure, levels of basic knowledge and skills of health staff, community involvement and utilization of health services were measured. Subjectivity of the data collection was minimized through use of a randomized study design, and external supervision. Comparability of results between the two surveys was assured by employing the same rapid assessment methodology, using a fixed set of indicators. The results suggest a marked improvement of the health services in Kabarole district since implementation of specific project activities and in direct response to action taken following review of information from the original survey work. Overall, it is felt that this particular method of project monitoring, and using the specific method, Systems' Analysis, generates data particularly useful to national governments and other health organizations.     

Exploring health care reform in a changing Europe: Lessons from Greece

Abstract

The economic crisis is the major theme in the Eurozone and its impact on public health and outcomes is largely discussed. Under this pressure, concerns of further inequalities exist that may have an impact on the burden of several diseases in certain European countries. In this context, Greece is currently an issue of top interest in any international economic discussion. Although the background of the recession has been largely discussed as a political crisis, its health effects on the population, as well as the key role of primary care and general practice/family medicine in health care reform remain to be explored. Serving both the worldwide trend of orienting health care systems towards strengthened primary care and the inner need for minimizing the demand and lessening the burden from the dysfunctional and costly hospital-care system, the economic crisis sets the perfect timing for prioritizing primary health care. In this article a unique window of opportunity for health care reform in Greece is examined, attempting to establish the axes of an example of how health care system can be reshaped amidst the economic crisis. Equity, quality, value framework, medical professionalism, information technology and decentralization emerge as topics of central interest. There is no doubt that Europe is transitioning under challenging social, economic and public health perspectives. However, taking Greece as an example, the current economic situation sets a good timing for health care reform and the key messages of this paper could be used by other countries facing similar problems.     

Patient care information systems and physicians: the transition from technology icon to health care instrument

We have discussed several important transitions now occurring in PCIS that promise to improve the utility and availability of these systems for the average physician. Charles Babbage developed the first computers as "thinking machines" so that we may extend our ability to grapple with more and more complex problems. If current trends continue, we will finally witness the evolution of patient care computing from information icons of the few to clinical instruments improving the quality of medical decision making and care for all patients.     

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.     

East Timor in transition: health and health care.

East Timor was liberated from 400 years of conquest and exploitation in an armed struggle that ended, in September 1999, in a conflagration that destroyed its social and physical infrastructures. For two years the territory has been under United Nations administration. Political conditions remain unstable as the result of many intrinsic and external factors. Its economy continues to depend upon infusions of funds from multilateral, bilateral, and private sources. Efforts by expatriates to introduce Euro-American cultural and technical models have been applied to the factors that determine health, with modest results. East Timor expects to be totally independent of foreign control early in 2002. Its future health will depend upon continuing collaboration between international and local leadership in evolving effective government, economy, and health services designed, managed, and executed by Timorese.     

Privatization and quality: Evidence from elderly care in Sweden

Non-contractible quality dimensions are at risk of degradation when the provision of public services is privatized. However, privatization may increase quality by fostering performance-improving innovation, particularly if combined with increased competition. We assemble a large data set on elderly care services in Sweden between 1990 and 2009 and estimate how opening to private provision affected mortality rates – an important and not easily contractible quality dimension – using a difference-in-difference-in-difference approach. The results indicate that privatization and the associated increase in competition significantly improved non-contractible quality as measured by mortality rates.     

Cree Indian healing practices and western health care: A comparative analysis

In this article, Cree Indian methods of treating disease are compared with the treatment process and procedures used in the Western health Care system. Ethnographic data permitted the identification of the five components of Cree healing: the ritual, contract, treatment, didactic, and closure components. These components are compared with equivalent phases in the physician-patient and nurse-patient relationship. In particular, the process of comparison permits the identification of incongruities that the Cree may encounter when using the Western system. These include the inability to identify one's own state of health and abnormalities; a passive, rather than a participatory role in healing; the incomprehensible notion of "silent" diseases and preventative treatment; the specialization of the caring, curing, and counselling roles of practitioners and the limited perspective of "holism" in health care.     

Privatization in the health care system of Croatia: effects on general practice accessibility

This paper analyzes some effects of the privatization process in primary health care in Croatia, and in particular evaluates actions taken by providers to improve their accessibility for patients. The sample was stratified by regional density of practices and the status of practices in relation to privatization. Three groups of general practices were included in the study and were assessed twice (in 1997/1998 and 1999/2000): (1) 106 privatized before the beginning of the study; (2) 96 privatized during the study period and (3) 65 that were not yet privatized. The research was performed by structured interview with general practitioners as informants. The indicators analyzed were: possibilities of obtaining first and follow-up visit appointments, honouring scheduled appointments, scheduling visits by telephone, visiting the practitioner after hours and obtaining telephone advice after working hours. Number of registered patients in the practice and perception of patients' waiting times were also assessed. Privatized practices performed better in improving the accessibility of their services for patients: they increasingly offered the possibility for first and follow-up appointments at precise times, scheduled visits by telephone and provided telephone advice outside working hours. They showed greater intention to honour made appointments in order to lower their patients' waiting times. The study indicates that, in the initial stage of privatization, practitioners tend to extend accessibility by structural improvements that are not time consuming. It seems that providers adjust the level of offered accessibility benefits according to the intensity of market competitiveness. Further research is needed to precisely delineate the range of structural adjustments that could be expected by privatization and to verify the effect of observed changes on the quality of care and health outcomes.     

Change in the control of health care systems in Europe Implications for professional autonomy

Major changes are taking place in European health care systems,especially those in the former communist countries. However,in Western European countries reorganization is also on itsway, guided by the rhetoric of deregulation and competition.This might lead to a convergence in the institutional controlof health care systems, although it appears that different pathshave been chosen by Eastern European health care systems andWestern national health services. It is argued that the implicationsof these changes for the professional autonomy of doctors differand this is influenced by the way health care changes tie upclinical autonomy and economical autonomy.     

Re-engineering trust: the adoption and adaption of four models for external quality assurance of health care services in western European health care systems.

Accreditation, ISO, EFQLM and visitatie are, in essence, control mechanisms in health care systems. An analysis is provided of the way the four models have been adopted and adapted in European health care systems over the past decade. After a short discussion of the major reforms in the European health care systems in the direction of regulated markets, deregulation and decentralization, the features of the four models are highlighted and it is explained how each of them can help to fill the 'accountability gap' between health care providers on the one hand and patients, financiers and governments on the other. The quality system perspective of ISO, the quality management development perspective of EFQM, the health care organization perspective of accreditation and the professional perspective of visitatie can each be appropriate given the balance of power between parties in the health care system and the focus and scope of accountability. Although a general convergence between the four models can be observed, actual convergence will depend on their adoption in specific health system contexts. Potential pitfalls for further convergence are the differences in distribution of responsibilities for quality of care among the various European countries, the drift away from clinical decision making, bureaucratic tendencies and too much focus on efficiency and patient empowerment compared with attention to medical effectiveness.     

Understanding referral from primary care clinics in rural Kenya: using health information systems to prioritize health services

This study analyses the referral patterns of patients, over time, from primary care to secondary or tertiary level facilities in rural Africa. The data come from a health information system of a non-governmental organization with a decade of experience in health services delivery in Samburu District, Kenya. The differential referral patterns from two communities are examined in some detail to shed more light on the meaning of a 'referral rate' in this context. First, referral rates over time for two clinics are calculated and compared. These quantitative data, obtained from monthly reports from 1989 to 1997, are interpreted in the light of qualitative data obtained from interviews with community health workers, nurses and members of the communities. The main differences in referral between these ostensibly similar communities are for malaria, trauma and anaemia. Social, environmental and specific health services factors are used to explain these differences. We demonstrate that basic information from health information systems, which tell us little on their own because referral in this context is a rare event, can be combined with local knowledge from the community to provide evidence for health managers to set priorities for public health and clinical interventions.