The shift from inpatient care to outpatient care in Switzerland since 2017: Policy processes and the role of evidence

The shift from inpatient care to the ambulatory sector is a central aspiration of European health systems. Despite demonstrated benefits, health reforms have struggled to realize their potential. In this context, we discuss recent hospital sector reforms in Switzerland and analyze the content, process, and role of evidence in the recent introduction of policies to substitute inpatient care with ambulatory care. The prevailing payment system incentivized hospitals to provide unnecessary and costly inpatient services, but federal reform on tariff structures was deemed politically unfeasible. Instead, driven by the pressure to contain costs, cantonal and federal health authorities began to deny reimbursement for selected inpatient procedures in 2017. These regulatory measures were effective in reducing inpatient admissions and health care costs. This case study illustrates that clear, simple messages about hospital sector reform can raise awareness of the need for change. However, the evidence used in the policy process was limited and not critically reviewed. Stakeholders used long-standing international comparisons of inpatient substitution potential to legitimize policies, but not to develop them. The analysis restates the importance of inter- and intranational comparative analyses and institutions such as health observatories and suggests aligning health system governance more proactively with international developments.     

Pricing and reimbursement of generic pharmaceuticals in Turkey: Evaluation of hypertension drugs from 2007 to 2013

Purpose

This study was designed to examine the effects of drug pricing and reimbursement politics on drug expenditures from January 2007 to September 2013, with a focus on internal reference pricing in Turkey.

Characteristics of trials and regulatory pathways leading to US approval of innovative vs. non-innovative oncology drugs

BackgroundSuccessful first-generation drugs can be converted with small alterations to "second-generation drugs," which are cheaper to develop and may pose less financial risk for manufacturers due to already validated action mechanism and a well-defined consumer market.MethodsWe found four classes of cancer drugs for first- and second generation products approved in the US: BCR-ABL tyrosine kinase inhibitors (TKI) for treatment of CML, ALK + TKI for NSCLC, CD20 monoclonal antibodies for CLL, and HER2 monoclonal antibodies for breast cancer. We analyzed the characteristics of the clinical trials and the approval pathways for these 14 drugs.ResultsFirst-generation and 4 out of 5 s-generation BCR-ABL TKI drugs were granted expedited approval, while all drugs were approved based on single-arm trials. Both ALK + TKI drugs were based on single-arm trials and expedited approval. The first-generation CD20 monoclonal antibody drug was approved based on single-arm trials, and one of the second-generation drugs had pivotal trials that were randomized. All benefited from expedited approval. All HER2 monoclonal antibodies in the sample were based on randomized trials and expedited pathways.ConclusionSecond-generation TKI and monoclonal antibodies were often approved through expedited regulatory pathways and studied in single-arm trials. This helps to facilitate the approval for earlier use by patients, but is also associated with greater risk of post-approval safety-related labeling changes or unanticipated adverse events.     

2009—2018年云南省手足口病流行特征分析

目的了解云南省2009—2018年手足口病流行特征,并提出防控建议。方法采用整群抽样,对云南省最近10年手足口病疫情及学校突发公共卫生事件进行描述性分析。结果云南省2009—2018年共报告手足口发病数647938例,年平均报告发病率为138.7019/10万,发病数以每年上升24.12%的速度递增,发病率以每年上升1.23倍的速度递增。高发地区主要为滇中的玉溪市(355.6680/10万)和昆明市(256.1449/10万),滇西北的丽江市(168.6435/10万),和位于滇西、滇南与缅甸和老挝接壤的德宏州(280.6515/10万)、西双版纳州(192.9979/10万),与越南接壤的红河州(164.8012/10万)。发病时间呈双高峰分布,主高峰为5月—7月(占42.65%),次高峰为10月—12月(占23.68%)。男、女发病数性别比为1.42:1,发病人群以1岁~5岁人群为主,占81.23%,并以散居儿童最多。手足口病突发公共卫生事件发生时间分布以6月(39起,占20.0%)和5月(35起,占17.95%)最多。结论近十年,云南省手足口病疫情持续逐年增长,云南省手足口病发病有明显的年龄、性别、地区和季节性差异,应有针对的在家长和幼教人员中开展健康教育。在5岁以下儿童中鼓励开展EV71疫苗接种。     

Writing social determinants into and out of cancer control: An assessment of policy practice

A large literature concurs that social determinants of health (SDH) are demonstrable, important, and insufficiently attended to in policy and practice. A resulting priority for research should be to determine how the social determinants of health can best be addressed. In this paper we support the more effective transfer of social determinants research into policy by: (1) describing a qualitative analysis of thirty-two cancer control policy documents from six English-speaking OECD countries and two transnational organizations, demonstrating great variability in the treatment of social determinants in these policies; (2) critiquing these various policy practices in relation to their likely impact on social determinants of health; and (3) advancing a tool that policy writers can use to assess the way in which social determinants of health have been addressed in their work. In the sample of policy documents, the distinction between structural and intermediate determinants, population-based and targeted interventions, and their respective relationships to equity were not always clear. The authors identified four approaches to social determinants (acknowledging SDH, auditing SDH, stating aims regarding SDH and setting out actions on SDH), and five ways of writing about the relationship between social determinants and cancer risk. These five discourses implied, respectively: that group membership was intrinsically risky; that not enough was known about SDH; that risk arose from choices made by individuals; that groups were constrained by circumstance; or that structural change was necessary. Socio-cultural factors were generally presented negatively, though New Zealand policies modeled a possible alternative. Based on their empirical work, the authors propose a matrix and a set of questions to guide the development and assessment of health policy.     

医院追求高价药巍然成风,降价药品百姓难以见面:以2000-2008年上海市医疗机构青霉素使用为例

通过对2000-2008年上海样本医院购药前100位中青霉素类药品销售额、加权价、剂型、规格以及不同价位药品销售情况分析,明确医院恶性补偿机制下,药品降价措施对医院青霉素购药用药的影响。研究发现,上海医院青霉素类用药占抗感染类比重、加权价格逐年下降;青霉素类药品剂型规格逐年增多,新剂型规格首年价格最高,此后年份逐渐下降,降到一定程度则退出市场;同剂型同规格的同种药品中,医院偏爱使用高价位药。可见,在恶性循环机制下医院"喜见高价药",药品降价措施效果难以惠及患者。因此,要想从根本上解决药价虚高等问题,必先解决医院恶性循环机制。     

Distributional equity as a consideration in economic and modelling evaluations of health taxes: A systematic review

Purpose/settingThe extent to which distributional equity is incorporated into evaluations of the (potential or observed) impact of health taxes is unclear. This systematic review of economic and modelling evaluations investigating taxation on tobacco, sugar-sweetened-beverages (SSBs), or alcohol aims to assess the proportion that have considered distributional impact by income or socioeconomic group. Secondary aims included summarising the reported distributional impacts, for both costs and health benefits.FindingsOf 4656 search results, 69 studies were included. The majority were economic analyses with epidemiological modelling, with studies on SSB taxes being of the highest quality. Tobacco was most commonly investigated tax, with 37 evaluations.Of these, 12 (32 %) considered distributional equity, with six (27 %) of 22 included SSB evaluations doing the same, and none for alcohol. A tobacco tax favoured lowerincome groups in the distribution of costs in all identified evaluations and for health benefits in nine out of 12 evaluations (75 %). For SSBs, four evaluations (67 %) found costs to favour low-income groups, with three (50 %) for health benefits.ConclusionsDespite recommendations, evaluations of health taxes do not routinely consider the distributional impact of both costs and health benefits. Evaluations for alcohol taxation are particularly weak in this regard. Where investigated, the majority of evidence found tobacco taxation to favour low-income groups, whereas the limited evidence for SSBs is mixed.     

Restructuring Public Health in Slovenia between 1985 and 2006

Summary Objective.  This paper explores the developments in the public health infrastructure in Slovenia in the context of the sociopolitical and legislative changes in health care over the last 20 years. It assesses the responsiveness of the public health institutes in Slovenia to the various plans on public health developed by health policy makers over time. Methods.  After an in-depth and externally validated search for key documents, we analysed the legislation, policy documents, research reports, theses, and other health policy papers related to the public health infrastructure in Slovenia. Findings were validated through consulting 3 external experts on public health in Slovenia. Results.  In the period discussed only few new services were added and health promotion was developed as an institutional field. Passivity in the past caused a lack of decisions on some traditional services in a changed economic environment. Moving from a passive supporter of the former infrastructure to an active promoter of the reform sets health policy as the main architect of the new public health building. Conclusion.  Slovenia’s “house” of public health was amended and refurbished, but a thorough reconstruction has not taken place. In order to face the future challenges in public health, the infrastructure will require increased efficiency, professional workforce development and better responsiveness. Submitted: 03 April 2007; Revised: 23 September 2007; Accepted: 22 December 2007     

The Road to the Alcohol Act 2018 in Finland: A conflict between public health objectives and neoliberal goals

Finnish alcohol policy has aimed for decades years to mitigate alcohol-related harm by using high taxation and restrictions on the physical availability of alcohol. The state monopoly on the retail of alcohol has played a central role in reducing the availability of alcohol. In 2011, preparations began for a comprehensive reform of the Alcohol Act 1994. Over time, the issue became highly politicised, lobbied and divisive. It took intense work of two consecutive governments to finalise the reform. The new Alcohol Act came into force in 2018. It expanded the rights of grocery stores to sell alcohol and reduced the administrative burden for on-premise sales. As a result, the state monopoly on the retail of alcohol was weakened, but it still has an important impact on the physical availability of alcohol. The Finnish public health community expected an increase in alcohol sales following the reform because of greater alcohol availability and expected price reductions related to greater competition of sales in grocery stores. However, prices decreased less than expected in 2018, partly due to a simultaneous increase in alcohol taxes. It is difficult to evaluate the impact of the reform at this early stage. However, after the reform, the 10-year (2008–2017) downward trend in the total per capita alcohol consumption was discontinued despite the tax increase. According to preliminary analyses, the change in the law may have slightly increased recorded alcohol sales but the effect was not statistically significant.     

The differential impact of the financial crisis on health in Ireland and Greece: a quasi-experimental approach

ObjectivesGreece and Ireland suffered an economic recession of similar magnitude, but whether their health has deteriorated as a result has not yet been well established.Study designBased on five waves (2006–2010) of the European Union Statistics of Income and Living Conditions (EU-SILC) survey a (DID) approach was implemented that compared trends in self-rated health in Greece and Ireland before and after the crisis with trends in a ‘control’ population (Poland) that did not experience a recession and had health trends comparable to both countries before the crisis.MethodsLogistic regression using a (DID) approach.ResultsA simple examination of trends suggests that there was no significant change in health in Greece or Ireland following the onset of the financial crisis. However, DID estimates that incorporated a control population suggest an increase in the prevalence of poor self-rated health in Greece (OR = 1.216; CI = 1.11–1.32). Effects were most pronounced for older individuals and those living in high-density areas, but effects in Greece were overwhelmingly consistent in different population sub-groups. In contrast, DID estimates revealed no effect of the financial crisis on the prevalence of poor self-rated health in Ireland (OR = 0.97; CI = 0.81–1.16).ConclusionsDID estimates suggest that the financial crisis led to higher prevalence of reporting poor health in Greece but not in Ireland. Although the research design does not allow the authors to directly assess the role of specific policies, contextual factors including policy responses may have contributed to the different effect of the crisis on the health of the two countries.     

Perceptions of politicization and HPV vaccine policy support

BackgroundSince its FDA approval in 2006, the Human papillomavirus (HPV) vaccine has been politically-charged, given its association with sexual health among young women and its history of controversial, and largely unsuccessful, legislative mandates. The extent to which perceived politicization is related to public support for the vaccine’s use, however, is not clear. We sought to examine the relationship between public perceptions of politicization of the HPV vaccine and public support for HPV vaccine policies.MethodsWe fielded a survey from May-June 2016 using a nationally representative sample of U.S. adults (18–59 years). Among respondents aware of the HPV vaccine (n = 290), we predict support for HPV vaccine policies based on respondents’ perceptions of three characteristics of the vaccine’s portrayal in public discourse: degree of controversy, certainty of the scientific evidence supporting the vaccine’s use, and frequency with which the vaccine appears in political discussion.ResultsRespondents who perceived greater certainty about the scientific evidence for the HPV vaccine were more supportive of HPV vaccine policies (p < 0.0001) than respondents who perceived the scientific evidence to be uncertain, after adjusting for respondents’ characteristics, including demographics and partisanship.ConclusionsPublic perceptions of the HPV vaccine’s politicization, particularly the portrayal of scientific evidence, are associated with receptivity to legislative mandates.Policy implicationsHow the certainty of a body of evidence gets communicated to the public may influence the policy process for a critical cancer prevention intervention.     

Reducing social inequities in health in Norway: Concerted action at state and local levels?

Norwegian national policies have been distinguished by their focus on equity, contributing to comprehensive policies to reduce the social inequities in health (SIH). The newly adopted Public health act, which aims at reducing the SIH, endorses these acknowledgements while highlighting the importance of municipalities as the key actors in public health. Municipal obligations include inter-sectoral policies for health, health impact assessments (HIA), and the development of local health overviews. Against the background of a system of local autonomy in Norway, this article illuminates whether, and how, municipal public health policies reflect national priorities. Our data are based on one qualitative study, combining document content analysis and expert interviews conducted in 2011, and one quantitative questionnaire sent to municipal chief administrative officers in 2011. Our findings indicate a divide between national and municipal public health strategies. Many municipalities focus on life-style and health-care related measures. Only few municipalities acknowledge the social determinants of health and have implemented HIA and health overviews. Arguing for the importance of concerted multi-level action to reduce the SIH, we need to better understand the gap between national and municipal approaches. We thus suggest further research to illuminate the challenges and success factors faced at local levels.     

The gradient in health inequalities among families and children: a review of evaluation frameworks

Public health policies and interventions that seek to tackle the social gradient in health need to be more adequately evaluated. The GRADIENT Project sets out to recommend public health policy options which effectively tackle health inequalities and address the gradient in health determinants among families and children in Europe. This work is underpinned by the development of a dedicated evaluation framework—a scheme that elaborates steps in a process of assessment which can act as a useful guide for decision makers. This paper presents the results from a narrative review, based on realist review principles, of 34 evaluation frameworks. It uses a set of analytical criteria, drawn from the EUHPID health development model, the Ottawa Charter for Health Promotion, and the wider literature on health inequalities, to analyse these frameworks. The findings reveal that no one suitable evaluation framework exists to evaluate whether policies and/or interventions targeting children and families reduce the health gradient. It is suggested that this work will be useful in assessing the complex nature of public health interventions and their evaluation. It will be used to develop an evaluation framework to guide decision makers to begin to understand the key drivers at each stage of the policy development and implementation cycle.     

Assessing public health policy approaches to level-up the gradient in health inequalities: the Gradient Evaluation Framework

Objectives

This paper seeks to introduce and analyse the development of the Gradient Evaluation Framework (GEF) to facilitate evaluation of policy actions for their current or future use in terms of their ‘gradient friendliness’. In particular, this means their potential to level-up the gradient in health inequalities by addressing the social determinants of health and thereby reducing decision-makers' chances of error when developing such policy actions.

Study design

A qualitative developmental study to produce a policy-based evaluation framework.

Methods

The scientific basis of GEF was developed using a comprehensive consensus-building process. This process followed an initial narrative review, based on realist review principles, which highlighted the need for production of a dedicated evaluation framework. The consensus-building process included expert workshops, a pretesting phase, and external peer review, together with support from the Gradient project Scientific Advisory Group and all Gradient project partners, including its Project Steering Committee.

Results

GEF is presented as a flexible policy tool resulting from a consensus-building process involving experts from 13 European countries. The theoretical foundations which underpin GEF are discussed, together with a range of practical challenges. The importance of systematic evaluation at each stage of the policy development and implementation cycle is highlighted, as well as the socio-political context in which policy actions are located.

Conclusions

GEF offers potentially a major contribution to the public health field in the form of a practical, policy-relevant and common frame of reference for the evaluation of public health interventions that aim to level-up the social gradient in health inequalities. Further research, including the need for practical field testing of GEF and the exploration of alternative presentational formats, is recommended.     

A structured tool to analyse coverage decisions: development and feasibility test in the field of cancer screening and prevention

Objectives

The comparison of fourth hurdle processes is challenging because they are heterogeneous and decision practice may deviate from formal process rules. This study applies a published framework consisting of key steps of coverage decision processes to the area of cancer prevention.

Methods

A research design was developed for analysis of case studies on past decision processes. Decisions were identified and information on the process steps was elicited by semi-structured telephone interviews with decision-makers and experts. The scheme was validated with experts from the areas of screening and prevention and fourth hurdle decision making.

Results

Indicators for a structured empirical comparison of coverage decisions were derived. Corresponding ordinal rankings were proposed. Details on six decisions about cancer screening (colorectal and prostate cancer) and vaccination against human papillomavirus in Sweden, Austria and Lithuania are presented.

Conclusions

The development of the structured scheme for analysis of coverage decisions allows validation of official statements on decision processes and collection of larger data sets for empirical analysis. However, the semi-structured phone interviews were time-consuming for collecting information on a larger number of decisions. Further validation of the structured scheme and development of a research tool for large-scale empirical studies is still needed.     

Brexit threatens the UK’s ability to tackle illicit drugs and organised crime: What needs to happen now?

BackgroundThe decision by the UK government to leave the European Union comes at a time when parts of the UK are experiencing a marked rise in reported gun and knife crimes. The health effects of Brexit will have serious consequences as to how the UK tackles this upsurge in drug-related crime.Health policy processesThe UK’s future participation with the EU’s specialised agencies will depend on the detail of any agreement reached on future collaboration with the EU and its drug agency, the EMCDDA.ContextThe EMCDDA provides the EU and its Member States with a factual overview of European drug problems and a solid evidence base to support debates on drugs policies. It also supports early warning initiatives and coordinates measures at national and supranational levels with Europol and supranational enforcement agencies.Expected outcomesWhile these arrangements might continue throughout any transition period, those working within the sector require guidance and assurances from the British government about its long-term intentions after any transition.ConclusionsThe scale of collaboration between the UK and European institutions is extensive. It is not clear how this might be replicated after Brexit. Yet an alternative framework of collaboration between the UK and the EU is clearly needed to facilitate shared and agreed approaches to data sharing and drug surveillance after Brexit.     

“There is always a better way”: Managing uncertainty in decision making about new cancer drugs in Canada

Policy decisions about the approval and funding of new cancer drugs must often be made in an environment of complex uncertainty about clinical and cost‐effectiveness data. The focus of this article is on the results from qualitative interviews with senior officials (n = 16) who make decisions about or influence cancer drug policy in various organizations in the Canadian cancer control system. Most participants identified the use of a limited number of informal approaches to address uncertainty, such as grounding decisions in evidence and advice from expert groups. People tended to focus on evidence informed decisions including price negotiations, the ability to implement policy changes, and stakeholder values. Lessons from the Canadian context related to continuing efforts to build a public culture of understanding into how policy decisions like cancer drug funding are made may result in greater acceptance and increased confidence in health policy decision‐making processes across multiple sectors internationally.