Evaluation of health care systems Contributions made by “the who world health report 2000”

Assessing and improving the performance of health systems is one purpose of public health activities. Health system indicators, health system profiles and health system goals among other approaches serve that purpose. The former two approaches are outlined in this article whereas the latter is - building on the World Health Report 2000 — analysed in detail for its innovations and shortcomings. As a result, the wealth of data about the level and distribution of good health, about the responsiveness of the health system, and about the financial contribution for health care across the population of 191 WHO member states are recovered as strengths. The methodology and components of the composite measures and WHO world ranking as well as the political discourse inherent to the World Health Report are identified as areas for improvement. WHO’s interim response to criticism - debate, consultation, report and website — is referenced as well.     

Household utilization and expenditure on private and public health services in Vietnam

The private provision of health services in Vietnam was legalized in 1989 as one of the country's means to mobilize resources and improve efficiency in the health system. Ten years after its legalization, the private sector has widely expanded its activities and become an important provider of health services for the Vietnamese people. However, little is known about its contribution to the overall objectives of the health system in Vietnam. This paper assesses the role of the private health care provider by examining utilization patterns and financial burden for households of private, as compared with public, services. We found that the private sector provided 60% of all outpatient contacts in Vietnam. There was no difference by education, sex or place of residence in the use of private ambulatory health care. Although there was evidence suggesting that rich people use private care more than the poor, this finding was not consistent across all income groups. The private sector served young children in particular. Also, people in households with several sick members at the same time relied more on private than public care, while those with severe illnesses tended to use less private care than public. The financial burden for households from private health care services was roughly a half of that imposed by the public providers. Expenditure on drugs accounted for a substantial percentage of household expenditure in general and health care expenditure in particular. These findings call for a prompt recognition of the private sector as a key player in Vietnam's health system. Health system policies should mobilize positive private sector contributions to health system goals where possible and reduce the negative effects of private provision development.     

Can productivity growth measures identify best performing hospitals? Evidence from the English National Health Service

Health‐care systems around the world face limited financial resources, and England is no exception. The ability of the health‐care system in England to operate within its financial resources depends in part on continually increasing its productivity. One means of achieving this is to identify and disseminate throughout the system the most efficient processes. We examine the annual productivity growth achieved by 151 hospitals over five financial years, using the same methods developed to measure productivity of the National Health Service as a whole. We consider whether there are hospitals that consistently achieve higher than average productivity growth. These could act as examples of good practice for others to follow and provide a means of increasing system performance. We find that the productivity growth of some hospitals over the whole period exhibits better than average performance, but there is little or no evidence of consistency in the performance of these hospitals over adjacent years. Even the best performers exhibit periods of very poor performance and vice versa. We therefore conclude that accepted methods of measuring productivity growth for the health system as a whole do not appear suitable for identifying good performance at the hospital level.     

Factors shaping intersectoral action in primary health care services

Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.     

The future of public health: a local health department view

This is an examination of factors responsible for the "disarray" in public health activities as described in the Institute of Medicine report on The Future of Public Health. It approaches the problem primarily from the viewpoint of the local health agency. Three contributing factors are discussed: disproportionate national expenditures for medical care as compared to public health funding; structural flaws in organization leading to functional difficulties; and medical profession opposition to an expanded role for local health departments. The problem of inadequately sized local governmental jurisdictions which are unable to supply sufficient resources for their health departments is discussed, and the complexities of remedial mergers across political boundaries are explored. Suggestions for improving the functions of local health departments include the provision of medical care services, not as a last resort as the Institute of Medicine report suggests, but as equal and perhaps superior competitors in the marketplace; increased state financial and technical support; and a proposed new federal program, The Health Objectives 2000 Act, S.2056, which will make specific provision to greatly strengthen health departments, facilitate the incorporation of missing skills and expertise in local health units, and enhance their capabilities to function as front-line agencies which are essential for achieving effective public health action.     

Knowledge for better health: a conceptual framework and foundation for health research systems

Health research generates knowledge that can be utilized to improve health system performance and, ultimately, health and health equity. We propose a conceptual framework for health research systems (HRSs) that defines their boundaries, components, goals, and functions. The framework adopts a systems perspective towards HRSs and serves as a foundation for constructing a practical approach to describe and analyse HRSs. The analysis of HRSs should, in turn, provide a better understanding of how research contributes to gains in health and health equity. In this framework, the intrinsic goals of the HRS are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Its four principal functions are stewardship, financing, creating and sustaining resources, and producing and using research. The framework, as it is applied in consultation with countries, will provide countries and donor agencies with relevant inputs to policies and strategies for strengthening HRSs and using knowledge for better health.     

Organization and financing of mental health care in Poland

ORGANIZATION OF CARE: Health care is provided to patients with mental disorders by the state health care facilities as well as by social help agencies. Mental health care services are provided mostly by mental health facilities and partly by primary care units. Outpatient clinics, separate for psychiatric patients and substance abusers, are the most numerous mental health care units, amounting to a total of 1120. Intermediate care facilities include 110 day hospitals, 23 community mobile teams and ten hostels. The number of hospital beds amounts to 31913, i.e. 8.3 beds per 10000 population. 80% of beds are located in mental hospitals. TRENDS OF DEVELOPMENT: The trends in mental health care development are outlined in the Mental Health Programme and accompanying documents accepted by the Minister of Health and Social Welfare. The programme defines specific goals to be achieved by the year 2005 in the primary, secondary and tertiary prevention of mental disorders. In the domain of mental health care accessibility the most important goals are the following: a significant reduction in the number of beds in large mental hospitals, a marked (nearly threefold) rise in the number of beds in psychiatric wards at general hospitals and a significant increase in the number of community-based forms of care (e.g. a fourfold rise in the number of day hospitals). FINANCING OF CARE: Before 1999, the health care system was financed from the state budget and the health care spendings were subject to a political auction each year. Allocation of funds among hospitals and health care centres was based on the total previous year budgetary spendings of particular facilities and did not take into account a detailed cost analysis. Such a financing approach, although giving a feeling of a relative financial safety, did not encourage health care facilities to introduce an organizational flexibility and to expand the scope of their services. In psychiatry, it manifested itself in a very slow development of some community psychiatry forms (mostly day hospitals, mobile community teams and hostels). The Health Care Institutions Act has created a legal framework for the financial management of health care units in their new, independent form. Conditions for health care financing through regional sickness funds were thus created. The financing is currently based on contracts made by sickness funds with health care facilities for specific health services. Both the quantity and price of services should be mutually negotiated. Some simplified measures of services offered were used during the first insurance financing year. In mental hospitals and day hospitals it was a person-day; in out-patient care it was a visit. Both cost indicators were aggregated, including all the components present so far in the functioning a given unit.     

Are you committing health care fraud under the False Claims Act? The answer may not be as simple as you think

Health care fraud has a significant financial effect on the operations of the American health care system. Governments and insurers are intent on quashing such fraud and have instituted massive efforts to indict and punish offenders as well as recover major monetary awards. This article provides examples of fraudulent practices and details the definitions of fraud and abuse. In addition, it characterizes the concept of qui tam that allows whistleblowers to share in any financial awards. Finally, it highlights the importance of proper coding as a means of reducing the suspicion of fraud or abuse.     

'Health transformation programme' in Turkey: an assessment

The aim of this study is to assess the 'Health Transformation Programme' (HTP) in Turkey announced in 2003. This assessment has been made according to the ultimate performance goals of a health care system, such as improvement in health status, financial risk protection and satisfaction with health care. This study provides a brief history of health policy since 1980, when the Turkish health care system began to transform with the introduction of both structural adjustment and market-oriented reform policy. The main aim of these reforms was increasing efficiency. Reform proposals of the 1990s focused on the introduction of a general health insurance (GHI) system, decentralization, introduction of a family medicine scheme, purchaser-provider split, contracting-out, quasi-markets and improvement of management information systems. Like the reform proposals of the 1990s, HTP has eight components, the major ones being a new role for the Ministry of Health (MoH), introduction of a GHI system, reorganization of health service delivery and human resources development. No component of HTP has yet been sufficiently realized. Therefore, despite some improvements, Turkish people continue to face low health status and a low level of financial risk protection. More research needs to be done for the determination of satisfaction with health services.     

Continuous innovation in health care: implications of the Geisinger experience

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform.     

The ethics of health service delivery: a challenge to public health leadership

The ethical distribution of health care is a central issue now that AIDS has started to be a drain on health care resources. If the worst predictions are true, the next half century will be capitalized by a great stress of the health care delivery system in the Pacific. The critical challenges that face the current leadership are: sustaining commitment to all levels of administration to reduce social and health inequities; making sound decisions on policies, priorities and goals that are based on valid information; strengthen health infrastructure, based on the principle of primary health care, including appropriate distribution of staffing, skills, technology and resources. The goals of the Pacific Health Promotion and Development center must not focus exclusively on AIDs. Hepatitis B control measures, hypertension and diabetes, primary care in remote areas, and rehabilitation initiatives must be kept in place. Humanitarian interests for AIDs patients must be balanced with the pragmatic reality of saving children's hearing, or extending useful lives. The attributes of respect, accountability, leadership, judgement, fairness, integrity and honesty controlled by principles of social justice must be part of the administrative decision making process. The 2 major issues facing public health professional are: (1) the financial considerations involved with increasingly expensive technology, services and research, contrasted against the need to prioritize their use and development; (2) pragmatic and ideological needs must be balanced to maximize preventative and curative services and make them available to those who can benefit from them.     

Collaborative population health planning between Australian primary health care organisations and local government: lost opportunity

Objective: To examine the strength and extent of collaborations between primary health care organisations and local government in population health planning. Methods: Methods included: a) online surveys with Medicare Locals (n=210) and Primary Health Networks (n=66), comparing the two using two‐level mixed models; b) interviews with Medicare Local (n=50) and Primary Health Network (n=55) executives; c) interviews with members of local government associations and Primary Health Network board members with local government experience (n=7); and d) review of 54 Medicare Local and 31 Primary Health Network publicly available annual reports. Results: Despite partnership being a policy objective for Medicare Locals/ Primary Health Networks, they reported limited time and financial support for collaboration with local government. Organisational capacity and resources, supportive governance and public health legislation mandating a role for local governments were critical to collaborative planning. Conclusions: Local government has the potential to tackle social factors affecting health; therefore, their inclusion in population health planning is valuable. Legislative mandates would help to achieve this, and PHNs require a stronger Federal Government mandate backed by sufficient resources and a governance structure that supports collaboration. Implications for public health: Improving primary health care and local government collaboration has great potential to improve the quality of health planning and action on social determinants, thus advancing population health and health equity.     

Quality oversight and improvement in Medicaid managed care.

New York State has been collecting performance data from managed care plans that serve the Medicaid population since 1993. The data come to the state via the Quality Assurance Reporting Requirements--a series of quality of care, access, and utilization measures, largely based on the Health Plan Employer Data and Information Set, as well as several New York State-specific measures. In addition to collecting the data, the state publishes the information, works with plans that have below average rates of performance and provides a number of program and financial rewards to plans for rates that demonstrate high quality care. An analysis conducted on quality of care measures indicates that: (1) performance rates are increasing over time, (2) Quality Assurance Reporting Requirements rates are generally higher than national benchmarks, (3) the disparity between commercial plan rates and Medicaid rates is diminishing, and (4) the variability in performance across plans is decreasing. The analysis conducted indicates that the performance measurement system constructed in New York is an effective means to monitor health plan performance, while at the same time enabling the state and local health units to monitor population health and accomplishment of key public health objectives (complete immunization, cancer screening, etc.)     

卫生项目政策简报撰写的方法与技巧:以中英全球卫生支持项目(GHSP)为例

卫生项目是开展国际卫生合作、落实一国卫生发展目标、任务的重要载体和平台,在推进全球卫生战略、深化医药卫生体制改革中发挥着重要的作用。政策简报是一种相对较新的为决策人员提供打包研究证据的工具,能够实现快速传递信息、交流经验、促进实施等目的。本文以中英全球卫生支持项目(Global Health Support Program,GHSP)为例,就卫生项目政策简报的功能特点、撰写要求、写作技巧等进行阐述,以帮助各级卫生管理人员掌握政策简报撰写的一般程序和方法,促进政策简报这一有效工具在我国医药卫生各领域得到更好的应用和发展。     

Straight talk--new approaches in healthcare. The performance improvement equation: quality care + efficient care = profitable care

Healthcare organizations that deliver high quality care as efficiently as possible inevitably are profitable. In the eleventh installment of Straight Talk, we discuss the performance improvement strategies of three health systems that strive to strike a balance between financial and altruistic goals: 15 hospital, $1.4-billion St. Vincent Health, Indianapolis, IN., formerly Central Indiana Health System and owned by Ascension Health, St. Louis.; 7 hospital, $1.8-billion Detroit Medical Center.; 3-hospital, $500-million Bon Secoure Richmond Health System, Richmond Va., which is part of Bon Secours Health System Inc., Marriottsville, Md. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on performance improvement was held on January 15, 2003 at Modern Healthcare's Chicago headquarters Fawn Lopez, associate publisher of Modern Healthcare, was the moderator.     

Transformational change in health care systems: an organizational model

BACKGROUND: The Institute of Medicine's 2001 report Crossing the Quality Chasm argued for fundamental redesign of the U.S. health care system. Six years later, many health care organizations have embraced the report's goals, but few have succeeded in making the substantial transformations needed to achieve those aims. PURPOSES: This article offers a model for moving organizations from short-term, isolated performance improvements to sustained, reliable, organization-wide, and evidence-based improvements in patient care. METHODOLOGY: Longitudinal comparative case studies were conducted in 12 health care systems using a mixed-methods evaluation design based on semistructured interviews and document review. Participating health care systems included seven systems funded through the Robert Wood Johnson Foundation's Pursuing Perfection Program and five systems with long-standing commitments to improvement and high-quality care. FINDINGS: Five interactive elements appear critical to successful transformation of patient care: (1) Impetus to transform; (2) Leadership commitment to quality; (3) Improvement initiatives that actively engage staff in meaningful problem solving; (4) Alignment to achieve consistency of organization goals with resource allocation and actions at all levels of the organization; and (5) Integration to bridge traditional intra-organizational boundaries among individual components. These elements drive change by affecting the components of the complex health care organization in which they operate: (1) Mission, vision, and strategies that set its direction and priorities; (2) Culture that reflects its informal values and norms; (3) Operational functions and processes that embody the work done in patient care; and (4) Infrastructure such as information technology and human resources that support the delivery of patient care. Transformation occurs over time with iterative changes being sustained and spread across the organization. PRACTICE IMPLICATIONS: The conceptual model holds promise for guiding health care organizations in their efforts to pursue the Institute of Medicine aims of fundamental system redesign to achieve dramatically improved patient care.     

Viewpoint: „Primary Health Care“ und globale Gesundheitsinitiativen

Background

Until just a short while ago the discussion about primary health care (PHC), the concept for providing basic health care in developing countries, had all but disappeared from the academic and political international health discourse. Has PHC been definitely replaced by new initiatives or does it now have a new chance, with wide-reaching consequences for health service provision globally?

Aim

The following contribution can be seen in terms of advocacy, intended on the one hand to explain the increasingly complex aid architecture and the difficulties of integrating this into national health policy and on the other to highlight the chances and potentials that a reinvigoration of PHC could bring with it.

Results

The controversy that surrounds the PHC concept vis-à-vis selective or vertical programmes has remained more confined to ideological arguments and has often not allowed the advantages and disadvantages of both approaches to be widely explored. The millennium development goals (MDGs) include some fundamental elements of the PHC approach but have paid little attention to the PHC principles. Parallel to the efforts towards the MDGs, we are experiencing a rapid increase in the number of global health Initiatives. To reach the MDGs additional financial means are indispensable. The international foundations and global health initiatives (GHIs) have shown that high level political advocacy and an intensive media presence are necessary to mobilize considerable financial resources. However, the concern exists that resource-rich GHIs can undermine and even weaken health systems. Questions remain regarding the extent to which GHIs and their means can be directed towards a long term investment in the PHC approach and whether sustainability can be assured.     

Overview: Health and the planning of health care systems

Implicit functions of a health care system which are often omitted or improperly emphasized are the study and promotion of individual health. This situation stems from the fact that health care systems are primarily based on the concept of disease, while the attributes of health (positive health) have not been investigated and objectively defined. However, an operational definition of the elusive concept of health appears possible today and is discussed in this paper. If the hypotheses that health can be improved and deterioration due to age can be retarded are accepted, then the consequences of these possibilities must be analyzed in relation to the planning of health care systems and to the planning of national health care programs. Thus, any attempt to describe the natural history of the health process must include the effects of interventions aimed at the promotion of health in the absence of disease. These effects must be defined so that quantitative criteria, which would serve as the basis for predictive medicine, can be established. Quantitative predictive medicine is necessary in order to evaluate the effectiveness of preventive measures. While it is widely recognized that the prevention of disease is one of the major goals of a health care delivery system, the methods presently used to evaluate alternative courses of action are notoriously limited.     

Uses of the concept of subjectivity in Public Health

This article analyzes the use of the concept of subjectivity in the public health field, associated with the historical and institutional conditions that demanded it. The main methodological strategy was a search in specific journals and reference books from the field. We identified three functions in the use of the concept of subjectivity, associating them primarily with external variables (trajectory in the health movement and institutionalization of the Unified National Health System - SUS) and secondarily with internal variables (logic of the theoretical/conceptual field). The functions discuss subjectivity as: (1) an element for conceiving the social action by political actors in the Health Reform project; (2) a strategy for problematizing health care and management as inter-subjective practices; and (3) a substrate for the production of autonomy for individuals and collectives. In their external variables, the three functions are established as processes for building micro and macro policies for the consolidation of the SUS.