Challenges to Latin-American health systems: what can be learned from the European experience?

This article compares the challenges of health systems in Latin America and the experience in Europe. The framework is the analysis of four functions: a) to generate resources; b) to produce activities; c) to finance, and d) to exercise stewardship. It is at this level where actors can influence health system responsiveness.Five challenges are identified in Latin America: a) to extend (prepayment and solidarity) financial protection; b) to stabilise that protection for crisis times; c) to equilibrate resources in accordance to capacity for financing services; d) to increase efficiency (technical and of placement) to produce services, and e) to improve the stewardship function in public and private sectors (the most important and difficult challenge Latin-American systems have nowadays).The experience of reform in Europe is analysed, showing: a) experiences about financial protection in Beveridge and Bismarck systems; b) stability in crisis times, recently confirm (West) and with important obstacles (East); c) efforts to equilibrate hospital beds and health care professionals, combining regulation and incentives; d) increase of efficiency in services production, with more express prioritisation, empowering patients, decentralising management and with market incentives, and e) improvement of stewardship with better (not less, sometimes even more) regulation.Three areas of European experience stand out: a) to combine solidarity with financial sustainability; b) to introduce market incentives in a measured way, but maintaining a clear stewardship role for the state, and c) to adopt innovations in organising and producing services.In spite of methodological difficulties, convergence of challenges and adopted solutions justify this analysis, but learning must be seen in each national context. A future article will analyse lessons offered by reform in Latin-American systems for European reforms.     

Tendering for outpatient prescription pharmaceuticals: what can be learned from current practices in Europe?

Objectives

To explore the current status (2010) of tendering programs for outpatient pharmaceuticals in the European countries and how these programs operate.

Methods

A survey was designed to assess the features of tendering programs in European countries. All 27 countries of the European Union plus Norway were included in the study. The survey was sent to national representatives of authorities and organizations and to academic researchers with expertise in the domain.

Results

Nineteen of the 28 countries have responded to the questionnaire (68%). Seven countries have adopted tendering programs for pharmaceuticals in ambulatory care. Tendering was more popular in countries with a mature generic medicines market (54%) than in countries with a developing generic medicines market (12.5%). A legal basis, criteria to grant the tender, the number of winners and the duration of the tender were amongst the features for the program to work.

Conclusions

Tendering programs can achieve savings in the short term. There are however some problems allied with the policy and the effects in the long term are still unclear. It can be concluded that the policy can work, but the features of the programs have to be well-thought-out.     

WHO's role in the global health system: what can be learned from global R&D debates?

Recent global debates on the research and development (R&D) of health technologies, such as drugs, diagnostics and vaccines, can be seen as a microcosm of discussions on the role of the World Health Organization (WHO) in the global health system more broadly. The global R&D system has come under heightened scrutiny with the publication of a 2012 report by the WHO Consultative Expert Working Group on Research and Development (CEWG), which made a number of recommendations to more equitably meet global health needs. The CEWG report followed a decade-long process of debate at the WHO on the weaknesses of the global R&D system, which include problems of affordability, limited research where market returns are small or uncertain (such as the ‘neglected diseases’ that predominantly affect the world's poorest), inefficient overlap of research efforts, and overuse of medicines such as antibiotics. The CEWG report called on WHO Member States to develop a global framework to improve monitoring, coordination and financing of R&D efforts through the establishment of a Global Health R&D Observatory and the negotiation of a binding treaty on R&D. While the treaty option has been put on the back-burner for several years, Member States nevertheless agreed at the 2013 World Health Assembly (WHA) on concrete steps towards a global framework. Progress at the 2013 WHA reaffirmed the central role of WHO as a convener, and the WHA's decision to create the Observatory within the WHO Secretariat underscored the organization's role as a source of strategic knowledge in the global health system. However, despite WHO's constitutional mandate as the ‘directing and coordinating authority on international health work’, in reality it faces major challenges in coordinating autonomous R&D actors such as states, firms and foundations in the global system. Strengthening its ability to do so requires, at a minimum, reforming its financing arrangements to provide it with a greater degree of independence from its largest donors. In addition, WHO may seem to be the natural arena for negotiating a binding R&D treaty, but negotiating new global agreements in other arenas such as the WTO, WIPO, or plurilateral fora offer the possibility of more enforceable and stronger public health norms. Nevertheless, no single arena in the existing system of global governance is perfectly suitable for the negotiation of progressive, inclusive, binding, enforceable, global health rules. While tradeoffs are inherent in the choice of any particular arena, leadership from either the multilateral institutions or influential governments can make a key difference in how beneficial any R&D treaty may be for health. In the coming years, global R&D debates will remain a critical issue to watch. The evolution of the global R&D system will be a harbinger not only of WHO's place in a rapidly-changing global health system, but also of our collective capacity to strengthen institutions of global governance for health.     

Estimating the mortality impacts of particulate matter: what can be learned from between-study variability?

Epidemiologic studies of the link between particulate matter (PM) concentrations and mortality rates have yielded a range of estimates, leading to disagreement about the magnitude of the relationship and the strength of the causal connection. Previous meta-analyses of this literature have provided pooled effect estimates, but have not addressed between-study variability that may be associated with analytical models, pollution patterns, and exposed populations. To determine whether study-specific factors can explain some of the variability in the time-series studies on mortality from particulate matter [less than/equal to] 10 microm in aerodynamic diameter (PM(10)), we applied an empirical Bayes meta-analysis. We estimate that mortality rates increase on average by 0.7% per 10 microg/m(3) increase in PM(10) concentrations, with greater effects at sites with higher ratios of particulate matter [less than/equal to] 2.5 microm in aerodynamic diameter (PM(2.5))/PM(10). This finding did not change with the inclusion of a number of potential confounders and effect modifiers, although there is some evidence that PM effects are influenced by climate, housing characteristics, demographics, and the presence of sulfur dioxide and ozone. Although further analysis would be needed to determine which factors causally influence the relationship between PM(10) and mortality, these findings can help guide future epidemiologic investigations and policy decisions.     

Private management of a public service: what can be learned from the CROS experience?

In January 2001, Canadian Radiation Oncology Services (CROS) was awarded the first-ever contract for the private management of a publicly funded department of radiation oncology. CROS saw its first patient in February 2001 and its last patient in August 2003. As of June 30, 2003, CROS had seen 2,018 patients, saving $30 million when compared to out-of-country referral. This raises several important questions.     

SARS epidemic in the world, from March to July 2003: what lessons can be learned from press coverage?

In the period from March to July 2003, the French and international press published a great deal of information and news about the first occurrence of the global SARS epidemic, due to its threat on numerous developed or lesser developed countries. The author collected all of the available French daily newspapers, dating from March 17 to July 31, 2003, and in particular every edition of the five national papers relaying any information on the epidemic covered on the front page. The review and study of these papers' headlines highlight the intense media coverage given in the French press primarily from April to May 2003, accompanied by an evolution of the themes being tackled above all which concerned the world-wide alert from WHO which originally comprised the countries of the East (mainly China) as well as Canada, European countries (including France) and finally whose scale reached that of global proportions. Due to this situation, certain countries adopted more drastic protective measures.     

Longitudinal exposure assessments of neighbourhood effects in health research: What can be learned from people's residential histories?

Health research into neighbourhood effects has generally examined neighbourhoods cross-sectionally, ignoring the fact that neighbourhood exposures might accumulate over people's lives and affect health outcomes later in life. Using longitudinal Dutch register data with complete 15-year residential address histories, we examined whether health effects of neighbourhood socioeconomic characteristics differ between cumulative and current exposures. We illustrated these differences between exposure assessments using suicide mortality among middle-aged adults. All suicides aged 40–64 years between 2012 and 2016 were matched with 10 random controls in a nested case-control design. We measured neighbourhood exposures longitudinally for circular buffers around residential addresses at the current address and through three accumulative measures, each incorporating the residential address history with increasing detail. Covariate-adjusted conditional logistic regressions were used to assess associations between suicide and neighbourhood social fragmentation, population density and unemployment rate. Our results showed that total and male suicide mortality was significantly lower in highly fragmented neighbourhoods when using accumulative exposures, but not when using the current residential address. However, we observed few differences in coefficients between exposures assessments for neighbourhood urbanicity and unemployment rate. None of the neighbourhood characteristics showed evidence that detailed cumulative exposures were a stronger predictor of suicide compared to more crude measures. Our findings provide little evidence that socioeconomic neighbourhood characteristics measured cumulatively along people's residential histories are stronger predictors of suicide mortality than cross-sectional exposures.     

The effects of price and policy on marijuana use: what can be learned from the Australian experience?

This research examines the responsiveness of the demand for marijuana to changes in its money price and criminal status using data on individuals from the Australian National Drug Strategy's Household Surveys (NDSHS). The results suggest that both the prevalence of marijuana use and the conditional demand for marijuana in the general population are responsive to changes in its money price. Significant differences are found in the effect of price on participation in marijuana use across age-groups, with participation by youth more price sensitive than participation by older age-groups. Similarly, the effect of the legal status of marijuana use on the participation decision is found to differ across age-groups and gender. Specifically, decriminalisation is associated with an increases in the prevalence of use by males over the age of 25. There is no evidence that decriminalisation significantly increases participation in marijuana use by either young males or females, or that decriminalisation increases the frequency of use among marijuana users.     

Can accurate data on birthweight be obtained from health interview surveys?

BACKGROUND: Because hospital records rarely exist for a representative sample of the population in developing countries, researchers frequently rely on birthweight data from surveys. Yet, the quality of these data has rarely been evaluated. This study explores the accuracy of birthweight information in six demographic and health surveys in Latin America conducted in the early 1990s: two in Guatemala, and one each in Bolivia, Costa Rica, El Salvador and Peru. METHODS: The quality of the birthweight reports is assessed by examining the plausibility of estimates of the proportion of newborns reported to have been weighed and estimates derived from the numerical weights, by characteristics of the delivery and maternal education. RESULTS: The estimates suggest that a substantial proportion of women whose newborns were probably never weighed report a birthweight. For all of the surveys, with the possible exception of Costa Rica, the average birthweights appear to be too high, and the estimates of the prevalence of low birthweight too low. In addition, the data reveal anomalous patterns, such as higher birthweights for home as compared with hospital deliveries. CONCLUSIONS: These findings suggest that estimates of low birthweight derived from surveys in developing countries are likely to portray an overly optimistic picture of children's and women's health status. More information about the underlying source of these data are needed not only to provide additional insight into the degree of error characterizing existing estimates, but also to improve data collection strategies in future health interview surveys.     

How can payback from health services research be assessed?

Throughout the world there is a growing recognition that health care should be research-led. This strengthens the requirement for expenditure on health services research to be justified by demonstrating the benefits it produces. However, payback from health research and development is a complex concept and little used term. Five main categories of payback can be identified: knowledge; research benefits; political and administrative benefits; health sector benefits; and broader economic benefits. Various models of research utilization together with previous assessments of payback from research helped in the development of a new conceptual model of how and where payback may occur. The model combines an input-output perspective with an examination of the permeable interfaces between research and its environment. The model characterizes research projects in terms of Inputs, Processes, and Primary Outputs. The last consist of knowledge and research benefits. There are two interfaces between the project and its environment. The first (Project Specification, Selection and Commissioning) is the link with Research Needs Assessment. The second (Dissemination) should lead to Secondary Outputs (which are policy or administrative decisions), and usually Applications (which take the form of behavioural changes), from which Impacts or Final Outcomes result. It is at this final stage that health and wider economic benefits can be measured. A series of case studies were used to assess the feasibility both of applying the model and the payback categorization. The paper draws various conclusions from the case studies and identifies a range of issues for further work.     

The European health potential: what can we learn from each other?

In this paper global differences in health between the 12 countries of the European Union are compared and related to variations in so-called determinants of health, especially socio-economic and life style factors and characteristics of the health care system in each country. This leads to two main conclusions. The first conclusion is that the health differences that exist within the European Union can only be partially explained by variations in determinants of health. Still, the comparison offers intriguing clues for improving health, containing cost and further research in the European Union. The second conclusion is that considerable data on health and determinants of health are collected in each country, but that international comparability is still limited. The ongoing activities in the standardization of European data collection need our full support.     

What lessons can be learned from telemedicine programmes in other countries?

Reviews of telemedicine literature have shown that about half of the published studies come from the USA. This suggests that there is a large potentially useful stock of research outside the USA that could be used to guide telemedicine decision-making in the USA. In the present study, a request was sent to eight international experts in telemedicine asking about successful telemedicine programmes that have been assessed and could potentially be implemented in the US health-care system. We also conducted a focused review of a few key publications in the field to identify examples of successful telemedicine programmes. The review found that in some specific areas, such as teleradiology, telemental health, telegeriatric applications, e-referrals and discharge letters, and integration of health-care organizations with telemedicine networks, applications successfully implemented in international settings would be suitable for implementation in the USA. If telemedicine programmes from other countries are disseminated to the USA, differences in health-care systems, and technological infrastructure will probably affect their chances of success.     

Methadone for cancer pain: what have we learned from clinical studies?

The analgesic ladder guideline proposed by the World Health Organization has been shown to be effective in controlling cancer pain in about 80 percent of patients, but the remaining 20 percent still experience pain. Several strategies have been used to manage refractory cancer pain and opioid toxicity. Switching opioids, alternative routes of opioid administration, optimizing adjuvants, and invasive procedures are proposed treatments. Extensive medical literature corroborates each one of those treatments. Rotation from one opioid to another is a noninvasive strategy to overcome opioid side effects and refractory pain. Frequently, methadone is used during opioid rotation. However, there is a lack of consensus on how to proceed on rotation from morphine to methadone. In the current era of evidence-based medicine, the medical literature fails to answer some cancer pain-management issues. The purpose of this review is to clarify a process for transitioning from morphine to methadone.