Liberalising trade in health services: constraints and prospects for South Asian countries

This paper attempts to examine the prospects and challenges associated with liberalising trade in health services in five South Asian countries, namely Bangladesh, India, Nepal, Pakistan and Sri Lanka. Country‐specific secondary information, a brief literature review of empirical studies and debriefing sessions with key stakeholders are employed to explore the issues related to liberalising health services trade. The health sectors in India, Nepal and Pakistan are scheduled under General Agreement on Trade in Services (GATS) classification, whereas those in Bangladesh and Sri Lanka are not. In Bangladesh, there is opportunity for investment in joint venture hospitals under Mode 3. Nonetheless, India is the largest trader in health services under all four modes. In Sri Lanka, cross‐border trade in healthcare services is found to be insignificant. Moreover, expertise in eye treatment in Nepal could also attract foreign investment in medical services under Mode 3. In contrast, Pakistan exhibits no potential under Mode 4, because of a lack of healthcare professionals. In this view, the prospects of trade in health services within the South Asian region under the four GATS modes are constrained by infrastructural, regulatory, perception‐related, logistical and cultural problems. Considering the level of development and commercial opportunities, regional integration in the health sector could be explored in such areas as telemedicine, medical tourism, cross‐border investment and capacity building of health personnel. These developments call for stronger and pro‐active government‐to‐government collaboration in the South Asian Association of Regional Cooperation (SAARC) region in a transparent and accountable manner. Copyright © 2013 John Wiley & Sons, Ltd.     

Sri Lanka and the possibilities of achieving universal health coverage in a poor country

Sri Lanka has been lauded for providing good health coverage at a low cost despite having a modest per capita income. This article identifies the unique historical factors that enabled Sri Lanka to achieve near universal coverage, but it also discusses how this achievement is now being undermined by inadequate government investment in health services, the burdens of non-communicable diseases, and the growing privatisation of health services. In doing so, the article highlights the challenges of achieving and maintaining universal health coverage in a relatively low income country with a health system designed to treat infectious diseases and provide child and maternal health services as the country undergoes an epidemiological transition from infectious to non-communicable diseases. Using updated information on developments in the Sri Lankan health system, this article argues, in contrast with earlier publications, that Sri Lanka is no longer providing good health at a low cost. It shows that Sri Lanka’s low investment in health is detrimental and not an asset to achieving good health. The article also questions the possibilities of providing coverage for noncommunicable diseases at a low cost. The article has four main sections. The first details Sri Lanka’s accomplishments in moving toward universal health coverage. The second identifies the factors enabling Sri Lanka to do so. The third describes the equity and access challenges the health system now confronts. The fourth assesses what the Sri Lankan experience suggests about the requirements for universal health coverage when providing health services for treating non-communicable diseases becomes an important consideration.     

我国贫困地区县域内健康扶贫工作进展与政策建议

通过健康扶贫政策梳理、定量分析卫生健康统计数据和典型案例分析,研究我国县域内健康扶贫工作的进展、成效及问题,提出后脱贫期县域内医疗卫生服务改革与发展的建议。整体上看,我国健康扶贫工作成效显著:医疗卫生机构"三个一"和医疗服务能力"三条线"目标基本实现;卫生技术人员配置基本达到"三个一"要求;贫困县床位和设备配置达到或接近全国平均水平;通过新建临床专科、开展新技术和新项目等,贫困县专科服务能力得到提升;此外,部分贫困地区积极探索县域内医疗卫生综合改革。今后,新脱贫地区面临的主要挑战是县域内卫生服务体系建设仍需加强,基层卫生人才队伍差距和财政投入与卫生改革协同不足三大主要问题。建议中央财政继续支持县域内卫生服务体系建设;以人才建设为抓手,提升县域内医疗服务能力;强化保障措施,推进县域内医疗卫生综合改革。     

A community-based approach to non-communicable chronic disease management within a context of advancing universal health coverage in China: progress and challenges

Paralleled with the rapid socio-economic development and demographic transition, an epidemic of non-communicable chronic diseases (NCDs) has emerged in China over the past three decades, resulting in increased disease and economic burdens. Over the past decade, with a political commitment of implementing universal health coverage, China has strengthened its primary healthcare system and increased investment in public health interventions. A community-based approach to address NCDs has been acknowledged and recognized as one of the most cost-effective solutions. Community-based strategies include: financial and health administrative support; social mobilization; community health education and promotion; and the use of community health centers in NCD detection, diagnosis, treatment, and patient management. Although China has made good progress in developing and implementing these strategies and policies for NCD prevention and control, many challenges remain. There are a lack of appropriately qualified health professionals at grass-roots health facilities; it is difficult to retain professionals at that level; there is insufficient public funding for NCD care and management; and NCD patients are economically burdened due to limited benefit packages covering NCD treatment offered by health insurance schemes. To tackle these challenges we propose developing appropriate human resource policies to attract greater numbers of qualified health professionals at the primary healthcare level; adjusting the service benefit packages to encourage the use of community-based health services; and increase government investment in public health interventions, as well as investing more on health insurance schemes.     

The impact of expanded health system reform on governmental contributions and individual copayments in the new Chinese rural cooperative medical system

In 2002, the Chinese central government created a new rural cooperative medical system (NCMS), ensuring that both central and local governments partner with rural residents to reduce their copayments, thus making healthcare more affordable. Yet, significant gaps in health status and healthcare utilization persisted between urban and rural communities. Therefore, in 2009, healthcare reform was expanded, with (i) increased government financing and (ii) sharply reduced individual copayments for outpatient and inpatient care. Analyzing data from China's Ministry of Health, the Rural Cooperative Information Network, and Statistical Yearbooks, our findings suggest that healthcare reform has reached its preliminary objectives—government financing has grown significantly in most rural provinces, especially those in poorer western and central China, and copayments in most rural provinces have been reduced. Significant intraprovincial inequality of support remains. The central government contributes more money for poor provinces than for rich ones; however, NCMS schemes operate at the county level, which vary significantly in their level of economic development and per capital gross domestic products (GDP) within a province. Data reveal that the compensation ratios for both outpatient and inpatient care are not adjusted to compensate for a rural county's level of economic development or per capita GDP. Consequently, a greater financial burden for healthcare persists among persons in the poorest rural regions. A recommendation for next step in healthcare reform is to pool resources at prefectural/municipal level and also adjust central government contributions according to the GDP level at prefectural/municipal level. Copyright © 2014 John Wiley & Sons, Ltd.     

Transforming Ottawa Charter health promotion concepts into Swedish public health policy

Swedish public health policy clearly illustrates how the concept of the Ottawa Charter for health promotion can be utilized at a national level. The impact has been more implicit than explicit. Public health has a long history in Sweden and much of the present and future is, and will be, linked to traditional values and structures. International input, however, has been essential to prompt new approaches and change. Health inequalities remain the major shortcoming. The Swedish system offers universal access to healthcare in a decentralized system. Still, primary healthcare, and the health services as a whole have not yet sufficiently embraced the idea of health promotion. Political attention to modern public health at the Prime Minister level was established in late 1980s. Since, continuous initiatives in terms of organization, infrastructure and funding have taken place. With regard to funding, a vast majority of the resources allocated to health promotion will be found outside the health sector. An interesting observation is that the Swedish public health policy with its 11 objective domains remains the same, also after a change of government. Future challenges include maintaining and developing an intersectoral mechanism for implementation, allocating more resources for intervention research to strengthen knowledge-based health promotion, and developing tools for coping better with the challenges of globalisation identified in the Bangkok Charter.     

美国卫生体系面临的挑战及对中国的启示

本文系统分析了美国卫生体系面临的挑战及其原因。文章认为美国卫生体系目前存在诸多挑战:卫生支出大幅增加、医疗服务利用不足与过度并存、健康水平低于大多数发达国家、基层医疗机构全科医生数量明显不足等。而国家立法的失误、卫生管理系统不够完善等是造成美国卫生体系面临众多挑战的主要原因。吸取上述美国的历史教训,结合中国国情,提出以下启示:应保障人人享有卫生保健的基本权利;重视和发挥政府以及基层医疗机构的作用;加强全科医生队伍建设;改革支付方式,控制医疗费用的增长;加强立法,合理处理医疗事故和纠纷。     

全球最有效率的医疗卫生体系如何应对挑战?——香港特别行政区的医疗管理体制、医疗改革举措及对内地的启示

我国医药卫生体制改革取得了有目共睹的成绩,在深化医改的过程中,可以更多参考借鉴其他华人社会的成功经验并汲取其教训。香港特别行政区的医疗卫生体系蜚声国际,高居"全球最有效率卫生体系"之冠。本文主要评析香港特区的医疗管理体制,遇到的挑战,以及近年来的重要医改举措,并总结其对内地医改的启示。香港的医疗卫生治理结构充分实现了"管办分开",解决了"九龙治水"问题,医管局管理体制具有较高的效率和专业性。但是香港特区医疗系统也面临诸多挑战,特区政府近年来推行了自愿医保、公私营协作计划、长者医疗券等若干医改政策,其中许多改革理念和政策工具可供内地医改借鉴。     

The economics of primary healthcare reform in Australia - towards single fundholding through development of primary care organisations

Objective: A strong primary care sector is widely acknowledged as a fundamental component of a well functioning health system and thus has been the focus of strategic reforms in a number of countries. This paper provides an economic analysis of primary healthcare reform, with the aim of identifying the key structural elements that are necessary to support enhanced models of primary health in the Australian context. Approach: This paper utilises economic theory, and draws upon empirical evidence and international experience to analyse primary healthcare reform to identify the structural elements necessary for an enhanced primary care sector. The aim of which is to improve health system performance. These structural elements are then critically examined in the Australian health system setting. Conclusion: For enhanced models of primary healthcare to promote efficiency, they must incorporate a number of key structural elements; notably: governance and purchasing responsibilities for primary care devolved to a meso‐level organisational structure through capitated single fundholding arrangements; blended payment methods for reimbursing providers; the establishment of a national quality and performance framework; and the development of primary care infrastructure. Implications: As the Federal government attempts to address recommendations of the National Health and Hospital Reform Commission, a window of opportunity now exists to pursue long overdue structural reforms to deal with the challenges facing the Australian health system. The paper advances the important structural features to primary healthcare that need to be embraced as the government attempts to pursue its health reform agenda.     

Central Service: How to Get Results from an Interview

According to a recent national survey of Hospital chief executive officers, financial challenges are their top concern, especially government reimbursement. Moreover, the patient faces greater deductibles forcing hospitals to prioritize price transparency. The Triple Aim program is a tool available to hospital management to help address these challenges. This study indicates that the Triple Aim is valuable to healthcare providers and patients by reducing medical errors, improving healthcare quality, and reducing costs on a per capita basis. Managerial implications are discussed for hospitals and health systems considering this approach to addressing financial challenges.     

Inter-state disparities in health care and financial burden on the poor in India

Over five decades of independence, India has made rapid strides in various sectors. However, its performance in social sectors and particularly the healthcare sector has not been too rosy. Being the State's responsibility the healthcare has traditionally been influenced by individual State's budgetary allocation. Consequently inter-state disparity in availability and utilization of health services and health manpower are distinctly marked. This has implications for achievement of Health for All for the nation as a whole. Keeping in view the significance of studying inter-state variations in healthcare, this study focuses on the performance of healthcare sector in 15 major States in India. This is attempted through a comparative analysis of various parameters depicting availability of health services, their utilization and health outcomes. Our analysis depicts the prevalence of considerable inequity favoring high income group of States. In terms of healthcare resources, for instance, it indicates that the high income States hold a superior position in terms of: per capita government expenditure on medical and public health, total number of hospitals and dispensaries, per capita availability of beds in hospitals and dispensaries and health manpower in rural and urban areas. These parameters of availability have an impact on utilization levels and health outcomes in these States. A comparative profile of high and low income States as well as middle and low income States, both in rural and urban areas, reaffirms a greater financial burden in availing treatment at OPD and inpatient in low income States. In line with the higher financial burden and low per capita health expenditure, the health outcome indicators also depict a disconcerting situation in regard to low income States. These States are marked by lower life expectancy and higher incidence of diseases as well as high mortality rates. In this regard, demand as well as supply side constraints are observed which restrain the optimum utilization of existing health services. Among the low income States the main constraints on the demand side include illiteracy, malnutrition, and lack of infrastructure in accessing the facilities. Certain state specific supply side factors add significantly to under-utilization in low income States. In some of the States, however, corrective actions have been initiated to overcome the problem of the quality and low utilization of health facilities. In due course of time, it is likely that proper implementation of these measures may result in improved utilization level of existing health services, which may be useful to improve health status indicators. Nonetheless, overcoming the current levels of regional disparities in healthcare across three income groups of States may also require additional resources. The latter could be mobilized through assistance of donor agencies and appropriate mix of social and private insurance. Ultimately mitigating the problem of regional disparities in healthcare and protecting the poor and vulnerable from financial burden may require establishing and maintaining proper linkages between socio-economic development and healthcare planning.     

Challenges of healthcare professionals in providing care to South Asian ethnic minority patients in Hong Kong: A qualitative study

Ethnic minorities across the globe encounter disparities in healthcare. While a great deal of research has been conducted on the experiences of these patients, studies focusing on the perspectives of healthcare professionals are limited, particularly in the context of Asia. This study explores the perceptions of and challenges faced by Hong Kong healthcare professionals in the provision of culturally appropriate care to South Asian ethnic minority patients. Taking a qualitative approach, interviews were conducted with 22 healthcare professionals. Two main themes were identified: ‘lack of support’ at the healthcare system level and ‘dysfunctional relationship with South Asian ethnic minority patients’ at the interpersonal level. Challenges at the healthcare system level include information outreach, cultural competency, utilisation of available resources and time and workload, whereas challenges at the interpersonal level include patient–provider interaction, patient–provider perceptions of illness and care and patient–provider sociocultural discordance. Intercultural care was found to be influenced by both the healthcare system and interpersonal characteristics. The study highlights the need for healthcare professional education and training in cultural competency, in order to improve the provision of intercultural care. Identifying the challenges faced by healthcare professionals and the implications of these challenges for the provision of healthcare to South Asian ethnic minority patients will help practitioners, policy makers and care provider agencies to improve quality of care and health outcomes for culturally diverse patients.     

Refining estimates of public health spending as measured in national health expenditures accounts: the United States experience.

Providing for the delivery of public health services and understanding the funding mechanisms for these services are topics of great currency in the United States. In 2002, the Department of Homeland Security was created and the responsibility for providing public health services was realigned among federal agencies. State and local public health agencies are under increased financial pressures even as they shoulder more responsibilities as the vital first link in the provision of public health services. Recent events, such as hurricanes Katrina and Rita, served to highlight the need to accurately access the public health delivery system at all levels of government. The National Health Expenditure Accounts (NHEA), prepared by the National Health Statistics Group, measure expenditures on healthcare goods and services in the United States. Government public health activity constitutes an important service category in the NHEA. In the most recent set of estimates, Government Public Health Activity expenditures totaled $56.1 billion in 2004, or 3.0 percent of total US health spending. Accurately measuring expenditures for public health services in the United States presents many challenges. Among these challenges is the difficult task of defining what types of government activity constitute public health services. There is no clear-cut, universally accepted definition of government public health care services, and the definitions in the proposed International Classification for Health Accounts are difficult to apply to an individual country's unique delivery systems. Other challenges include the definitional issues associated with the boundaries of healthcare as well as the requirement that census and survey data collected from government(s) be compliant with the Classification of Functions of Government (COFOG), an internationally recognized classification system developed by the United Nations.     

The Syrian public health and humanitarian crisis: A ‘displacement’ in global governance?

Ongoing failure by the international community to resolve the Syrian conflict has led to destruction of critical infrastructure. This includes the collapse of the Syrian health system, leaving millions of internally displaced persons (IDPs) in urgent need of healthcare services. As the conflict intensifies, IDP populations are suffering from infectious and non-communicable disease risks, poor maternal and child health outcomes, trauma, and mental health issues, while healthcare workers continually exit the country. Healthcare workers who remain face significant challenges, including systematic attacks on healthcare facilities and conditions that severely inhibit healthcare delivery and assistance. Within this conflict-driven public health crisis, the most susceptible population is arguably the IDP. Though the fundamental ‘right to health’ is a recognised international legal principle, its application is inadequate due to limited recognition by the UN Security Council and stymied global governance by the broader international community. These factors have also negatively impacted other vulnerable groups other than IDPs, such as refugees and ethnic minorities, who may or may not be displaced. Hence, this article reviews the current Syrian conflict, assesses challenges with local and global governance for IDPs, and explores potential governance solutions needed to address this health and humanitarian crisis.     

Healthcare-financing reforms in transitional society: a Shanghai experience

Since the 1950s, China has had a very wide coverage of healthcare service at the local level. In urban areas, the employment-based healthcare-insurance schemes (Government Insurance Scheme and Labour Insurance Scheme) worked hand in hand with the full employment policy of the Government, which guaranteed basic care for almost every urban resident. However, since the economic reforms of the early 1980s, China's healthcare system has met great challenges. Some came from the reform of the labour system, and other challenges came from the introduction of market forces in the healthcare sector. The new policy of the Chinese Government on the Urban Employees' Basic Health Care Insurance is to introduce a cost-sharing plan in urban China. Like other major social policy changes, this new health policy also has a great impact on the lives of the Chinese people. Affordability has been the major concern among urban residents. Shanghai implemented the cost-sharing healthcare policy in the spring of 2001. It may be too early to assess the pros and cons of the new policy, but evidence shows that the employment-based health-insurance scheme excludes those at high risk and in most need. It is argued that the cost-sharing healthcare system will limit access by some people, especially those who are most vulnerable to the consequences of ill health and those in low-income groups, unless the deductibles vary according to income and unless low-income groups are exempt from paying premiums and deductibles.     

Reconstruction of health service systems in the post-conflict Northern Province in Sri Lanka

Public health problems in armed conflicts have been well documented, however, effective national health policies and international assistance strategies in transition periods from conflict to peace have not been well established. After the long lasted conflicts in Sri Lanka, the Government and the rebel LTTE signed a cease-fire agreement in February 2002. As the peace negotiation has been disrupted since April 2003, a long-term prospect for peace is yet uncertain at present. The objective of this research is to detect unmet needs in health services in Northern Province in Sri Lanka, and to recommend fair and effective health strategies for post-conflict reconstruction. First, we compared a 20-year trend of health services and health status between the post-conflict Northern Province and other areas not directly affected by conflict in Sri Lanka by analyzing data published by Sri Lankan government and other agencies. Then, we conducted open-ended self-administered questionnaires to health care providers and inhabitants in Northern Province, and key informant interviews in Northern Province and other areas. The major health problems in Northern Province were high maternal mortality, significant shortage of human resources for health (HRH), and inadequate water and sanitation systems. Poor access to health facilities, lack of basic health knowledge, insufficient health awareness programs for inhabitants, and mental health problems among communities were pointed by the questionnaire respondents. Shortage of HRH and people's negligence for health were perceived as the major obstacles to improving the current health situation in Northern Province. The key informant interviews revealed that Sri Lankan HRH outside Northern Province had only limited information about the health issues in Northern Province. It is required to develop and allocate HRH strategically for the effective reconstruction of health service systems in Northern Province. The empowerment of inhabitants and communities through health awareness programs and the development of a systematic mental health strategy at the state level are also important. It is necessary to provide with the objective information of gaps in health indicators by region for promoting mutual understanding between Tamil and Sinhalese. International assistance should be provided not only for the post-conflict area but also for other underprivileged areas to avoid unnecessary grievance.     

Universal Health Coverage in Italy: lights and shades of the Italian National Health Service which celebrated its 40th anniversary

The Italian National Health Service (I-NHS) was established in 1978 to guarantee universal access to healthcare. Prominent in international reports, the I-NHS has reached a satisfactory level of efficiency and excellent standards of care in many regions, in forty years. Along the years, I-NHS has developed a structural public-private partnership in health services delivery that in some regions contributes to the achievement of very high standards of healthcare quality. However, the I-NHS is currently facing some major challenges: (a) Italy is experiencing a remarkable aging of its population with increasing health needs; (b) the recent and constant cuts to public expenditures are reducing the budget for welfare. It is of utmost importance to ensure that on-going efforts to contain health system costs do not subsume health care quality. In addition, monitoring of the essential levels of care (Livelli Essenziali di Assistenza, LEA) highlights significant differences in healthcare delivery among Italian regions that, in turns, contribute to the burdensome migration of patients to best-performing regions. Therefore, a more consolidated and ambitious approach to quality monitoring and healthcare improvement at a system level is needed to guarantee its sustainability in the future.     

社会办医的新时期：机遇、挑战与对策

国家对社会资本举办医疗机构的重视不断增强,社会办医的发展具备政策、经济和社会等方面的条件,社会办医发展不断加速.但加快发展社会办医仍然存在目标和定位不清、社会资本引入动力不足、可持续性发展困难、政府和市场角色混淆和监管不力等问题.本文在分析了社会办医发展现状的基础上明确了加快发展社会办医的机遇与挑战,并提出了应对挑战的对策建议,即拓宽社会办医的服务内容与人群、创造良好的资本进入环境、促进社会办医可持续性发展、明确政府和市场在社会办医中的职能和加强对社会办医的监管.     

An insight into burns in a developing country: a Sri Lankan experience

Burn injuries represent a diverse and varied challenge to medical and paramedical staff. The management of burns and their sequelae in a well-equipped, modern burns unit remains demanding despite advances in surgical techniques and development of tissue-engineered biomaterials; in a developing country, these difficulties are amplified many times. Sri Lanka has a high incidence of burn-related injuries annually due to a combination of adverse social, economic and cultural factors. The management of burn injuries remains a formidable public health problem. The epidemiology of burns, challenges faced in their management and effective strategies specific to Sri Lanka, such as the Safe Bottle Lamp campaign, are highlighted in this paper.