欧洲卫生筹资模式的改革

基于WHO欧洲委员会"增加财富与增进健康的卫生系统--塔林宪章"的卫生改革框架,卫生服务的筹资模式已经成为欧洲卫生改革的重点.本文从卫生筹资的角度系统地介绍了欧洲国家近年来所实施的改革政策与措施.通过增加公共财政投入、建立多元化的筹资模式、维护医疗保险制度的稳定性、提高统筹基金的抗风险能力以及改变支付方式来加强政府卫生...     

临沂市社区居民对社区护理服务认知与利用的调查分析

目的 了解临沂市社区居民对社区护理服务的认知与利用情况,分析其存在的问题,并提出相应的对策.方法 采取分层随机抽样的方法对临沂市5个社区18周岁以上的居民使用自行设计调查问卷进行面对面的调查与访谈.结果 目前临沂市社区护理普及程度不高;社区护理服务经费不足;社区护士工作的重点仍然是疾病护理,疾病预防和健康促进涉及较少,社区护理服务功能尚未充分体现出来.结论 应加强社会宣传,提高社区居民对社区护理工作的认识;逐步加大对社区护理工作的资金投入;逐步拓宽社区护理服务领域,满足社区人群的健康需求.     

Viewpoint: A Pragmatic Approach to Constructing a Minimum Data Set for Care of Patients with HIV in Developing Countries

Providing quality health care requires access to continuous patient data that developing countries often lack. A panel of medical informatics specialists, clinical human immunodeficiency virus (HIV) specialists, and program managers suggests a minimum data set for supporting the management and monitoring of patients with HIV and their care programs in developing countries. The proposed minimum data set consists of data for registration and scheduling, monitoring and improving practice management, and describing clinical encounters and clinical care. Data should be numeric or coded using standard definitions and minimal free text. To enhance accuracy, efficiency, and availability, data should be recorded electronically by those generating them. Data elements must be sufficiently detailed to support clinical algorithms/guidelines and aggregation into broader categories for consumption by higher level users (e.g., national and international health care agencies). The proposed minimum data set will evolve over time as funding increases, care protocols change, and additional tests and treatments become available for HIV-infected patients in developing countries.     

Allocation of health care resources: a challenge for the medical profession.

If current limitations on health care funding continue, medical practitioners will face increasing pressure to conserve scarce resources and to participate in the allocation of funds. This article discusses the ethical and economic aspects of the physician's role and briefly reviews some efficiency measures that might mitigate the effects of rationing of health care services.     

Federal health financing

The CMA believes that financial support from the federal government for health care should provide for the following. [List: see text]

The CMA is committed to preserving the right of reasonable access to high-quality health care regardless of ability to pay. It is also committed to maintaining the national health care standards (accessibility, universality, portability, comprehensiveness and public administration) and developing health goals to ensure that all Canadians receive the best possible care when required. The CMA supports the goal of maintaining the national integrity of the health care system. It encourages the federal government to be sensitive to the concerns of equity and to ensure that provinces and territories that have not attained a level of health care services and facilities equivalent to those of other provinces and territories, because of fiscal incapacities, have access to additional funding requirements to reduce the gap. The CMA views stability in funding as essential to effective health care planning and believes that unplanned and unilateral federal reductions may compromise accessibility and quality of patient care.

     

Shifting visions: "delegation" policies and the building of a "rights-based" approach to maternal mortality

"Rights-based" approaches fold human rights principles into the ongoing work of health policy making and programming. The example of delegation of anesthesia provision for emergency obstetric care is used to demonstrate how a rights-based approach, applied to this problem in the context of high-mortality countries, requires decision makers to shift from an individual, ethics-based, clinical perspective to a structural, rights-based, public health perspective. This fluid and context-sensitive approach to human rights also applies at the international level, where the direction of overall maternal mortality reduction strategy is set. By contrasting family planning programs and maternal mortality programs, this commentary argues for choosing the human rights approach that speaks most effectively to the power dynamics underlying the particular health problem being addressed. In the case of maternal death in high-mortality countries, this means a strategic focus on the health care system itself.     

E-Health: A Global Approach with Extensive Semantic Variation

In recent years, there has been considerable attention towards the development of information and communication technology (ICT) in health care delivery known as 'E-Health'. The term "E-Health" is almost a new concept and the E-Health projects mainly aim to improve service delivery to people, though different countries might have different approaches in using E-Health. The focus of this study is to review factors influencing the development of E-Health projects, as these factors could lead to an extensive semantic variation. This study reviews the E-Health status in different countries based on existing reports and documents about E-health projects in developed and developing countries and also based on the reports and documents provided by WHO, International Telecommunication Union (ITU); and World Bank. The review of the documents showed that the E-Health status in different countries is depended upon three key factors including the potential of ICT, economic capacity and the level of health status. The review of the documents indicated that there might be different meanings for the concept of E-Health in different countries, and the semantic variation in E-Health concept is related to the level of E-Health developments and implementations. Therefore, developing a clear definition of E-Health is needed.     

Liberal benefits, conservative spending. The Physicians for a National Health Program proposal

The Physicians for a National Health Program proposes to cover all Americans under a single, comprehensive public insurance program without copayments or deductibles and with free choice of provider. Such a national health program could reap tens of billions dollars in administrative savings in the initial years, enough to fund generous increases in health care services not only for the uninsured, but for the underinsured as well. We delineate a transitional national health program budget that would hold overall health spending at current levels while accommodating increases in hospital and physician utilization. Future national health program spending would be indexed to the growth in gross national product adjusted for demographic, epidemiologic, and technologic shifts. Financing for the national health program would transfer funds into the public program without disrupting the general pattern of current revenue sources. We suggest a funding package that would augment existing government health spending with earmarked health care taxes. Because these new taxes would replace employer-employee insurance premiums and substantial portions of current out-of-pocket expenditures, they would not increase health costs for the average American.     

广西新型农村合作医疗现状、问题及对策研究

为了解广西新型农村合作医疗现状,本研究从参合情况、筹资情况、保障情况、基金使用情况等四个方面进行分析,以期为广西新型农村合作医疗提供参考依据。本研究发现,新农合的参与度有待提高,新农合筹资机制有待完善,参合居民保障水平有待提高,新农合基金使用率有待提高。因此,政府应当加大宣传力度,完善新农合筹资机制,逐步提高新参合农村居民保障水平,加强对新农合基金的管理。     

中国“赤脚医生”始末

我国“文化大革命”时期农村中出现了“赤脚医生”这一新生事物,利用了最少的经费培训出最多的准卫生员,为占人口比例最多的农民解决了最难解决的医疗问题。“赤脚医生”和合作医疗走出了一条具有中国特色的低收入、高产出、穷国办大卫生的农村卫生发展道路。“赤脚医生”在为农村居民提供基本卫生保健服务和健康保障方面发挥了主要作用,对国际初级卫生保健理念形成起到了一定的促进作用。随着时代的发展,“赤脚医生”已经退出了历史舞台,但它提示给我们一条必须遵循的原则,农村一级卫生预防保健网的作用不能削弱,更不能缺失。     

上海漕河泾地区“城中村”健康教育方法初探

目的了解上海漕河泾地区"城中村"居民卫生常识的认知水平,探索行之有效的健康教育方法改善当地居民健康知识认知水平。方法对漕河泾地区"城中村"居民卫生常识的认知程度进行调查与比较,采用现场干预试验的方法对徐汇区漕河泾地区"城中村"150名居民实施不同方式健康教育活动干预措施。结果本次调查显示150名居民文化程度普遍较低,以小学和初中为主(占89.4%),通过实施健康教育,居民卫生常识认知合格率从30.00%提高到62.67%,前后比较差异有统计学意义(P<0.05)。结论通过有计划、有组织、有系统地开展"城中村"居民社区健康教育活动,提高他们卫生常识的知晓率,使之自觉采纳有益于健康的行为和方式,消除或减轻影响健康的危险因素,从而提高和改善这部分人群的疾病防治、促进健康的意识及行为水平。     

On-Site Investigation of the Early Phase of Bhutan Health Telematics Project

Telemedicine is valuable to many developing countries. International use of telemedicine is widespread. Telemedicine can improve health care in the developing countries by removing time and distance barrier, and optimize the use of limited health services in developing countries. The purpose of this paper is to investigate the current situation of healthcare services and telecommunications infrastructure in Bhutan. It summarizes the experience gained from a previous telemedicine pilot project initiated and implemented by the Telecommunication Development Bureau, International Telecommunication Union (BDT/ITU). It also introduces the priorities of telemedicine development set out by the local health authorities as well as the international organizations. By analyzing the common and most urgent problems in the country, which could be alleviated by using telemedicine, it formulates several recommendations concerning the future development strategy of telemedicine in Bhutan.     

Health, globalization and developing countries

In health care today, scientific and technological frontiers are expanding at unprecedented rates, even as economic and financial pressures shrink profit margins, intensify competition, and constrain the funds available for investment. Therefore, the world today has more economic, and social opportunities for people than 10 or 100 years since globalization has created a new ground somewhat characterized by rapid economic transformation, deregulation of national markets by new trade regimes, amazing transport, electronic communication possibilities and high turnover of foreign investment and capital flow as well as skilled labor. These trends can easily mask great inequalities in developing countries such as importation and spreading of infectious and non-communicable diseases; miniaturization of movement of medical technology; health sector trades management driven by economics without consideration to the social and health aspects and its effects, increasing health inequalities and their economic and social burden creation; multinational companies' cheap labor employment promotion in widening income differentials; and others. As a matter of fact, all these factors are major determinants of ill health. Health authorities of developing countries have to strengthen their regulatory framework in order to ensure that national health systems derive maximum benefit in terms of equity, quality and efficiency, while reducing potential social cost to a minimum generated risky side of globalization.     

An expert consultation system for frontline health workers in primary eye care

In developing countries, blindness is a major health problem whose control depends on the application of simple measures by frontline workers because, in many of these countries, specialist medical care is not readily available. To assist primary health workers in the management of common and potentially blinding eye disorders, we have developed a prototype computer program for a hand-held computer that incorporates a set of guidelines for diagnosis and treatment. This eye treatment program will help evaluate the potential of such devices for improving health care delivery in developing countries. This approach is now feasible because of recent advances in expert system and portable computer technology.     

Physicians'' perceptions of the effect on clinical services of an alternative funding plan at an academic health sciences centre

BACKGROUND: In July 1994 an alternative funding plan for clinical services (global funding instead of fee-for-service payment) was established at the Southeastern Ontario Health Sciences Centre, Kingston, Ont. This study describes the perceptions of the referring physicians and consultants of the effects of the alternative funding plan 2.5 years after it was initiated. METHODS: A questionnaire was mailed to all physicians in the Kingston area in November 1996. Information was collected on demographics, referring physicians' perceptions of the funding plan's impact on their practices, consultants' perceptions of its impact on their activities, perceptions of referring and consultant physicians of its impact on services provided by consultants, and attitudes toward alternative funding in the context of the Ontario health care system. RESULTS: Of the 772 physicians 531 (68.8%) returned a completed questionnaire (323 referring physicians and 208 consultants). A sizeable proportion of the referring physicians (126 [39.0%]) indicated that they were referring fewer patients to consultants at the study centre. They did not think that their practice volume had increased, but they did report spending more time on complex cases and on patient care after referral or hospital stay, and more time coordinating community care after hospital stay. Of the consultants 81 (38.9%) believed that their time spent on patient care had increased. No consistent impact on time spent on research or teaching activities was perceived. A total of 54 (26.0%) of the consultants were concerned about the impact of the alternative funding plan on quality of care. A significant proportion of the respondents (399 [75.1%]) believed that outpatient waiting times had increased, and 116 (35.9%) of the referring physicians believed that consultants were not as available by telephone. Most (220 [68.1%]) of the referring physicians believed that the funding change had had a negative effect on health care services in the region, and 87 (41.8%) of the consultants agreed. Nevertheless, the respondents believed that other factors such as funding cuts, hospital bed closures and staff layoffs were much more responsible than the alternative funding plan for their negative perceptions. INTERPRETATION: The alternative funding plan appears to have had an impact on the practices of individual physicians. However, it was not the focus for significant opposition or support from either consultants participating in the funding plan or referring physicians.     

Low cost methods for secondary prevention of cervical cancer in developing countries

BACKGROUND: Cervical cancer is both a preventable and a curable disease- preventable because the pre-invasive stage can be detected by screening and curable because the very early stage can be cured. It is the commonest genital cancer among females in Nigeria. The incidence and mortality from this disease in developing countries is very high. This is due to the unavailability of organised screening programmes. To address this problem, effective and practical alternatives to cytology are being investigated in many studies. OBJECTIVE: To examine the strengths and limitations of new methods currently undergoing evaluation for secondary prevention of cervical cancer in developing countries. MATERIAL AND METHODS: We conducted a computerised literature search for published articles. Mesh phrases used for the search were cervical cancer screening, cervical cancer screening in developing countries, cervical cancer screening- new techniques. Hand searches of journals and the proceedings of major conferences were also done. RESULTS: The visual tests for screening for cervical cancer was found to be highly sensitive and can be performed by not only physician but also other trained health care providers. The "single visit approach" to prevention of cervical cancer also referred to as "see and treat" has been tried in some countries in Asia and Africa and found to be effective and acceptable to women and their partners. CONCLUSION: Several studies conducted in many developing countries have shown that low cost methods for cervical cancer prevention do have a place in reducing the incidence of this deadly disease.     

"There they go again"--hCG and weight loss

Dr. Albrink's review of information available in 1969 did not allow her to determine a physiologic basis for the use of hCG or any proof of immediate or long term benefit. Subsequent discoveries and clinical studies only support her impressions. Despite these facts, this form of therapy has achieved a resurgence in popularity. The difference today is that patients no longer have to rely on health care providers to prescribe their medications since internet sites allow them to obtain medications "on line". This has potential adverse ramifications when we consider that the initial use of gonadotropins derived from the human pituitary was discontinued due to the iatrogenic transmission of Creutzfeld-Jakob disease. It is thought that the disease is transmitted by an abnormal protein called prion protein. Subclinical forms of the disease exist and the prions could potentially be transmitted in urine. No cases or transmission via urine have been reported and reputable sources of hCG would appear to be safe, but products from countries with greater risk have the potential for contamination. The increased demand for hCG from reputable sources has led to shortages and increased expense for the legitimate uses of hCG in treatment of endocrine disorders and infertility. Obesity and the adverse impact on health has become a priority in public health policies for the state of West Virginia and for our nation as a whole. The benefit of longevity in the practice of medicine is that one is given the opportunity to observe attempts to "reinvent the wheel" where medical practices that have been previously disproven are reintroduced. Fineberg and Hiatt state this more eloquently when they said: "What is unacceptable is to persist in demonstrably ineffective practices either because we fail to collect systematic information about the effects of our actions or because we establish and respond to inappropriate incentives." Systematic information has been obtained and has shown lack of evidence for the benefit of this therapy. The alternative explanation for the persistence and promotion of this treatment is unacceptable.     

National surveillance of AIDS in health care workers

Information obtained for all persons with the acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control, Atlanta, includes a question about employment in a health care or clinical laboratory setting. As of May 1, 1986, a total of 922 (5.5%) of 16,748 adults with AIDS reported employment in such settings. Ninety-five percent of these health care workers belonged to recognized high-risk groups for AIDS; the proportion with "no identified risk" has not increased with time. All AIDS patients (including health care workers) who do not belong to high-risk groups are referred for further investigation. Of 88 health care workers initially reported with no identified risk, ten were from countries where heterosexual transmission is believed to play a major role; additional information was unobtainable or incomplete for 17 individuals. Of 61 persons on whom interviews or other follow-up information was obtained, 44 (73%) were reclassified. Specific occupational exposures that could be implicated as the source of human immunodeficiency virus infection were not identified for any health care workers with AIDS. A review of surveillance data supports other studies indicating that the risk of human immunodeficiency virus transmission in the occupational setting is low.     

From "silos" to seamless healthcare: bringing hospitals and GPs back together again

Linda Mann, a Sydney GP, proposes ways of potentially enhancing patient care and reducing hospital stays, without increasing overall healthcare costs. Her suggested solutions include making it simpler for all healthcare practitioners involved in caring for the same patient to share (rather than not share) all patient information by applying the information technology of today (rather than tomorrow). Also, pooling some funding from state and federal sources could allow for further "seamless care" at areas of reasonable overlap between the current "silos" of hospital-based and community-based care.     

Addressing a State's Physician Workforce Priorities Through the Funding of Graduate Medical Education: The TennCare Model

Robert L. Summitt, MD, MS; R. Robert Herrick, MS; Manuel Martins, MPA

JAMA. 1998;279:767-771.

TennCare is Tennessee's innovative program that replaces the state's Medicaid program with a health care system based on managed care and designed to cover the vast majority of the state's poor and uninsured. The program provides health care benefits not only to those eligible for Medicaid, but also to the uninsured poor who do not qualify for Medicaid and those who are uninsurable because of existing medical conditions. This article describes the allocation of TennCare graduate medical education funding, which is designed to address the state's physician workforce priorities regarding specialty mix and practice location. Under the new TennCare graduate medical education funding design, funds flow to the state's 4 medical schools and then to the sites of the residents' training. Allocation to the medical schools is based primarily on the number of primary care residents in residency programs under sponsorship of each.