“Diagnosing” Saudi health reforms: is NHIS the right “prescription”?

This paper outlines the health context of the Kingdom of Saudi Arabia (KSA). It reviews health systems development in the KSA from 1925 through to contemporary New Health Insurance System (NHIS). It also examines the consistency of NHIS in view of the emerging challenges. This paper identifies the determinants and scope of contextual consistency. First, it indicates the need to evolve an indigenous, integrated, and comprehensive insurance system. Second, it highlights the access and equity gaps in service delivery across the rural and remote regions and suggests how to bring these under insurance coverage. Third, it suggests how inputs from both the public and private sectors should be harmonized – the “quality” of services in the private healthcare industry to be regulated by the state and international standards, its scope to be determined primarily by open‐market dynamics and the public sector welfare‐model to ensure “access” of all to essential health services. Fourth, it states the need to implement an evidence‐based public health policy and bridge inherent gaps in policy design and personal‐level lifestyles. Fifth, it points out the need to produce a viable infrastructure for health insurance. Because social research and critical reviews in the KSA health scenario are rare, this paper offers insights into the mainstream challenges of NHIS implementation and identifies the inherent weaknesses that need attention. It guides health policy makers, economists, planners, healthcare service managers, and even the insurance businesses, and points to key directions for similar research in future. Copyright © 2012 John Wiley & Sons, Ltd.     

“Enticing case study” or “celebrated anomaly”? Policy learning from the Cuban health system

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.     

Are public health authorities able to “steer” rather than “row”? An empirical analysis in the Italian National Health Service

The nature of the local health authorities (LHAs) in the Italian National Health Service has been deeply reformed during the 1990s by new public management (NPM) reforms that introduced decentralization, quasi-market and managerialism. These reforms implied that the main role of LHA is to govern the production of health services in their area (steer) rather than to only directly produce services (row). After more than 15 years from these reforms of Italian healthcare, we describe how much the steering versus rowing dichotomy made an impact on LHA activity, through an analysis of the management control systems they set up for themselves and the subsequent qualitative analysis of the opinions that a diverse group of managers expressed during 8 days of group discussion. Results show that managers of Italian LHAs, when only a small part of services is produced, tend to perceive their steering role as impossible to play and focus on production, leaving therefore ungoverned a significant part of the services offered to residents. NPM, therefore, was able to influence the reform of Italian healthcare but, as suggested by a postmodernist interpretation, left managers with a rhetoric change based on inconsistent assumptions instead of actionable ideas to manage the change process.     

Injury surveillance in construction: What is an “injury”, anyway?

BACKGROUND: Over the last decade, there has been a decline in injuries with days away from work in construction, associated with an increase in injuries with restricted work activity only. METHODS: We abstracted demographics, diagnosis, cause-of-injury, and hospital discharge information for 481 workers from one large construction project treated in an urban Emergency Department (ED). The project safety team provided data on all injuries from this site, including first aid cases. RESULTS: This site had fewer injuries with days away from work than expected from national rates. Two hundred and fifty-six injuries were reported on the OSHA log, and of those 93 entailed days away from work; 1,515 injuries were considered first aid/medical only. We used a sample of the data to estimate that the site classified as "recordable" 128 of the 481 ED-treated injuries from this site (27%). CONCLUSIONS: The pattern of injury varies depending on the subset of injuries examined. Lost time injuries, as reported in BLS data, record fewer lacerations and eye injuries, and more strains and sprains. No one surveillance system presents the full spectrum of occupational injury. Tracking all injuries allow early recognition of injury risks, and therefore can lead to more effective prevention.     

“Bottoming Out?” Among Rural African American Women Who Use Cocaine

CONTEXT: Studies have explored the spiraling-down effect of losing individual, familial, and social resources among African Americans who use drugs, but there is a gap in knowledge about this "bottoming-out" phenomenon among rural African American women. PURPOSE: The study was conducted to better understand the phenomenon of bottoming out among rural African American women who use cocaine. METHODS: Using an ethnographic approach, researchers drew on multiple qualitative and quantitative data collection methods. Data derived from qualitative interviews, field notes, and demographic profiles describe the phenomenon or lack thereof of bottoming out among 25 southeastern rural African American women who use cocaine. Data collection took place in a rural county of north Florida with a population between 11,000 and 15,000. Twenty-five African American females 18 years or older who used either powder or crack cocaine at the time of enrollment and resided in the rural county participated in the study. FINDINGS: Respondents used 6 major strategies that delayed or prevented them from bottoming out: (1) taking advantage of their social environment and community ties, (2) utilizing various sources of income, (3) accessing family resources, (4) maintaining some degree of discipline over spending for drugs, (5) maintaining routine drug use locations, and (6) renting cheap housing and/or house pooling. CONCLUSION: Unlike studies of similar populations in urban settings, most respondents continued to work after numerous years of drug use, tended not to lose legal custody of their children, maintained a support system of nonusers as well as users over time, and securred food, clothing, and shelter for themselves and in many instances their children using legal or illegal means.     

What does “Getting to ZeroTM Through the Power of One” mean to you?

Hopefully by now you've heard the mantra and are now aware of ASHRM's initiative of “Getting to Zero^TM Through the Power of One.” But what does that mean to you? And how can you forward the message on to your colleagues and coworkers? It's as simple as looking at it this way: “Everyone is a risk manager.”     

Use of Levonorgestrel Emergency Contraception In Utah: Is It More than “Plan B”?

CONTEXT: It is important to understand why some women use levonorgestrel emergency contraceptive pills repeatedly, because the method is not intended for repeated use, and current evidence suggests that it is approximately 77% effective at preventing pregnancy. METHODS: An anonymous patient survey of 1,040 women aged 18–29 purchasing levonorgestrel at Planned Parenthood clinics in Utah was conducted during a 4–6‐week period in 2007. Chi‐square tests and analyses of variance were used to examine associations between selected characteristics and level of levonorgestrel use. Logistic regression was used to assess characteristics independently associated with repeated use. RESULTS: Twenty‐nine percent of participants had used levonorgestrel more than twice in the prior year. Fifty‐eight percent believed that levonorgestrel is at least 90% effective in protecting against pregnancy; 16% believed that it is 100% effective. In univariate analyses, lifetime number of partners, currently having multiple partners, substance use at last intercourse and perceived effectiveness of levonorgestrel were positively associated with repeated levonorgestrel use in the previous year. The measure most strongly associated with repeated levonorgestrel use in multivariate analyses was perceived effectiveness: Women who believed that the method is 90–99% or 100% effective in preventing pregnancy had greater odds of repeated use than those who believed it is 75–89% effective (odds ratios, 1.8 each). CONCLUSION: Women who repeatedly use levonorgestrel may have an inflated perception of its effectiveness. Future research, including qualitative research, may help clarify factors that lead to inflated perceptions of effectiveness.     

Benefit–Cost in the California Treatment Outcome Project: Does Substance Abuse Treatment “Pay for Itself”?

OBJECTIVE: To examine costs and monetary benefits associated with substance abuse treatment. DATA SOURCES: Primary and administrative data on client outcomes and agency costs from 43 substance abuse treatment providers in 13 counties in California during 2000-2001. STUDY DESIGN: Using a social planner perspective, the estimated direct cost of treatment was compared with the associated monetary benefits, including the client's costs of medical care, mental health services, criminal activity, earnings, and (from the government's perspective) transfer program payments. The cost of the client's substance abuse treatment episode was estimated by multiplying the number of days that the client spent in each treatment modality by the estimated average per diem cost of that modality. Monetary benefits associated with treatment were estimated using a pre-posttreatment admission study design, i.e., each client served as his or her own control. DATA COLLECTION: Treatment cost data were collected from providers using the Drug Abuse Treatment Cost Analysis Program instrument. For the main sample of 2,567 clients, information on medical hospitalizations, emergency room visits, earnings, and transfer payments was obtained from baseline and 9-month follow-up interviews, and linked to information on inpatient and outpatient mental health services use and criminal activity from administrative databases. Sensitivity analyses examined administrative data outcomes for a larger cohort (N=6,545) and longer time period (1 year). PRINCIPAL FINDINGS: On average, substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487, representing a greater than 7:1 ratio of benefits to costs. These benefits were primarily because of reduced costs of crime and increased employment earnings. CONCLUSIONS: Even without considering the direct value to clients of improved health and quality of life, allocating taxpayer dollars to substance abuse treatment may be a wise investment.     

Do preschool children understand what it means to “diet,” and do they do it?

OBJECTIVE: The current study determined what preschool children understand about dieting and the extent to which they report engaging in dieting behaviors. METHOD: Forty-two children (mean age = 5.2 years) were interviewed about their understanding of the word "diet" and about food restraint behaviors. Children's height and weight were recorded. RESULTS: Only 17% of the children provided an accurate definition of the word diet (i.e., an answer having to do with the foods a person eats). None of the children mentioned weight loss in their definition. Children reported occasional use of restraint behaviors. Girls and heavier children reported more use of restraint. DISCUSSION: Children did not have a clear understanding of the word diet. Thus, the use of the word diet should be avoided when assessing eating behaviors in preschool children. Individual differences in reported dieting behaviors were in the expected directions, suggesting validity in these reports and early emerging social pressures to diet.