The standard of care debate: can research in developing countries be both ethical and responsive to those countries' health needs?

To avoid exploitation of host communities, many commentators argue that subjects must receive the best methods available worldwide. Others worry that this requirement may block important research intended to improve health care, especially in developing countries.To resolve this dilemma, we propose a framework for the conditions under which it is acceptable to provide subjects with less than the best methods. Specifically, institutional review boards should assume a default of requiring the "worldwide best" methods, meaning the best methods available anywhere in the world, in all cases.However, institutional review boards should be willing to grant exceptions to this default for research studies that satisfy the following 4 conditions: (1) scientific necessity, (2) relevance for the host community, (3) sufficient host community benefit, and (4) subject and host community non-maleficence.     

The health care rationing debate: more clarity by separating the issues?

The health policy debate about rationing is often confused by dealing with several different issues concurrently. This contribution introduces a typology and matrix that separates two of the most important of these issues in order to improve the clarity of the debate. The first of these issues, the mode of rationing, concerns how the responsible parties allocate scarce resources. This can be achieved non-systematically, for example, via ad hoc clinical bedside reasoning, or systematically with the aid of rigorously developed and tested algorithms, possibly including elucidated public preferences which trade-off efficiency and equity. The second issue, the transparency of the debate, concerns how the debate is presented, should it happen tacitly being left to the parties involved (hidden) or should it be open to public scrutiny (open)? Thinking about mode and transparency separately may lend more clarity to the rationing debate. The paper also discusses possible implications resulting from such a separation.     

The health care rationing debate: more clarity by separating the issues?

The health policy debate about rationing is often confused by dealing with several different issues concurrently. This contribution introduces a typology and matrix that separates two of the most important of these issues in order to improve the clarity of the debate. The first of these issues, the mode of rationing, concerns how the responsible parties allocate scarce resources. This can be achieved non-systematically, for example, via ad hoc clinical bedside reasoning, or systematically with the aid of rigorously developed and tested algorithms, possibly including elucidated public preferences which trade-off efficiency and equity. The second issue, the transparency of the debate, concerns how the debate is presented, should it happen tacitly being left to the parties involved (hidden) or should it be open to public scrutiny (open)? Thinking about mode and transparency separately may lend more clarity to the rationing debate. The paper also discusses possible implications resulting from such a separation.     

The debate over health care rationing: Déjà vu all over again?

Health care rationing has been a source of contentious debate in the United States for nearly 30 years. Because rationing is bewildering to many Americans, persistent myths about "death panels" and critical health care decisions to be made by faceless bureaucrats abound, instilling fear about health care reform and cost containment measures aimed at slowing spending growth. This paper retrospectively reviews the policy literature on health care rationing over the past quarter century, examines alternative definitions and classification schemes, traces the evolution of the debate, and explores ways in which rationing may be made more rational, transparent, and equitable in the future allocation of scarce health care resources.     

Greening health care: how hard can that be?

There are two key policy questions when addressing climate change and health care: where do we start and how do we move forward? This pragmatic exploration of the climate change issue and its impact on health care delivery starts from the premise that a proper understanding of the scope of the problem and a focus for bringing a broad range of people together to develop solutions is the place to begin policy discussions. Far from a standing start, there is much work already underway at the global and local levels. What is recommended is a forum that can bring people and ideas together in a creative, engaged and cross-generational dialogue that prepares for change in health care to meet the challenge of climate change.     

Can primary care be both patient-centred and community-led?

Examines the relationships between the macro-, meso-, and micro-levels in the NHS at the end of the fundholding period and considers their contemporary implications for primary care groups (PCGs) and local health care co-operatives (LHCCs). Fundholding achieved some success in challenging the way in which services were provided at the micro-level (the practice), but had a less marked effect in terms of changing service provision at the health authority (meso-) level or in developing collaborative working with trusts and health authorities in strategic decision making. The health authorities prioritized alternative models of devolved commissioning. Trusts regarded fundholders as a distraction who exerted influence and commanded trust management time disproportionate to their "market share". PCGs and LHCCs represent a shift back to the meso-level in service planning and purchasing. As such there is a risk that the micro-level benefits of fundholding and other forms of devolved commissioning will be lost, while uncertainties remain regarding the capacity of PCGs and LHCCs to incorporate GPs into a collaborative approach to strategic decision making.     

Sovereign immunity and health care: can government be trusted?

When government provides or arranges for health care, it is held to lower legal standards than private parties are, especially when liability is barred by "sovereign immunity". This paper examines sovereign immunity and its implications for health care quality by comparing private-sector and government accountability in several legal contexts. It then considers whether the law should be changed; the possible relationship between limited government accountability and public mistrust of a larger government role in health care; and the potential role of disparate legal standards if a lower tier of care evolves in government programs.     

The national health service plan: further reform of British health care?

Less than three years after initiating a series of health service reforms, the Blair government has launched another plan for the U.K. National Health Service. This article considers the origins and contents of the plan. A major investment program is designed to bring health care spending up to European averages over the next five years. In return, the government seeks to challenge the existing settlement between organized medicine and the state through tighter regulatory control, altered contractual frameworks, and a new public-private concordat. The plan does not represent a radical change in government policy but rather reaffirms existing approaches to increasing access to health services, integrating health and social care, and empowering users. Notwithstanding arrangements to increase the autonomy of health service organizations, the plan increases central control through a range of new bodies and regulatory frameworks. It represents an incremental adjustment of the existing tax-funded system. Should this reinvigoration of the state monopoly fail, alternative sources of funding will no doubt have to be reconsidered.     

Managing for health: why health care?

Health and health care are increasingly big business. The challenge is to apply our knowledge and skills to meet people's needs, if not their demands as efficiently, effectively and beneficially as possible. Value for money is the slogan. For those who deliver the goods as required, the converse, money for value should equally apply, and not only in a market driven system. This paper offers a very personal view of these issues in the light of recent UK policy developments.     

The Malcolm Baldrige National Quality Award concept: could it help stimulate or accelerate health care quality improvement?

The United States has a major weapon in the battle to improve competitiveness: The Malcolm Baldrige National Quality Award Program. An increasingly asked question in industrial and health care sectors is whether there should be a Baldrige Award in health care. In the business community, the Baldrige Award has been a catalyst for cooperative development of quality criteria, assessment mechanisms, and continuous learning, greatly accelerating the pace of information sharing.     

The health care assistant: professional supporter or budget necessity?

The budgets of NHS Trust Hospitals are continually under scrutiny in an endeavour to reduce operating costs. Skill mix, the balance of professional staff to non-professional staff, is a part of this process and the NHS has introduced a new level of staff called "health care assistants" (HCA). Examines the role and training of the HCA, and the reaction of professional nurses to their introduction into the area of patient care. Highlights areas of concern in relation to HCA training, selection techniques, and the absence of national guidelines which would ensure the quality level of HCAs produced. There is evidence of some managements leaning towards "cheaper:" staffing, i.e. using HCAs to replace professional nurses, and the conclusions give rise to some concern in quality of patient care and in the falling morale of professional nurses.     

Is universal health coverage the practical expression of the right to health care?

Background

Public stigma against family members of people with mental illness is a negative attitude by the public which blame family members for the mental illness of their relatives. Family stigma can result in self social restrictions, delay in treatment seeking and poor quality of life. This study aimed at investigating the degree and correlates of family stigma.

Methods

A quantitative cross-sectional house to house survey was conducted among 845 randomly selected urban and rural community members in the Gilgel Gibe Field Research Center, Southwest Ethiopia. An interviewer administered and pre-tested questionnaire adapted from other studies was used to measure the degree of family stigma and to determine its correlates. Data entry was done by using EPI-DATA and the analysis was performed using STATA software. Unadjusted and adjusted linear regression analysis was done to identify the correlates of family stigma.

Results

Among the total 845 respondents, 81.18% were female. On a range of 1 to 5 score, the mean family stigma score was 2.16 (±0.49). In a multivariate analysis, rural residents had significantly higher stigma scores (std. β?=?0.43, P?<?0.001) than urban residents. As the number of perceived signs (std. β?=?-0.07, P?<?0.05), perceived supernatural (std. β?=?-0.12, P?<?0.01) and psychosocial and biological (std. β?=?-0.11, P?<?0.01) explanations of mental illness increased, the stigma scores decreased significantly. High supernatural explanation of mental illness was significantly correlated with lower stigma among individuals with lower level of exposure to people with mental illness (PWMI). On the other hand, high exposure to PWMI was significantly associated with lower stigma among respondents who had high education. Stigma scores increased with increasing income among respondents who had lower educational status.

Conclusions

Our findings revealed moderate level of family stigma. Place of residence, perceived signs and explanations of mental illness were independent correlates of public stigma against family members of people with mental illness. Therefore, mental health communication programs to inform explanations and signs of mental illness need to be implemented.