The changing role of health‐oriented international organizations and nongovernmental organizations

Apart from governments, there are many other actors active in the health policy arena, including a wide array of international organizations (IOs), public‐private partnerships and non‐governmental organizations (NGOs) that state as their main mission to improve the health of (low‐income) populations of low‐income countries. Despite the steady rise in numbers and prominence of NGOs, however, there is lack of empirical knowledge about their functioning in the international policy arena, and most studies focus on the larger organizations. This has also caused a somewhat narrow focus of theoretical studies. Some scholars applied the ‘principal‐agent’ theory to study the origins of IOs, for example, other focus on changing power relations. Most of those studies implicitly assume that IOs, public‐private partnerships and large NGOs act as unified and rational actors, ignoring internal fragmentation and external pressure to change directions. We assert that the classic analytical instruments for understanding the shaping and outcome of public policy: ideas, interests and institutions apply well to the study of IOs. As we will show, changing ideas about the proper role of state and non‐state actors, changing positions and activities of major stakeholders in the (international) health policy arena, and shifts in political institutions that channel the voice of diverging interests resulted in (and reflected) the changing positions of the health‐oriented organizations‐and also affect their future outlook. Copyright © 2015 John Wiley & Sons, Ltd.     

Children's environmental health--an international perspective

Parents in all countries want and deserve safe and healthy environments for their children. Children in all countries need, as part of normal growth and development, regular and frequent opportunities to interact with their environments as they learn to crawl, run, climb, swim, and explore. Environmental scientists and regulators recognize that environmental hazards are not contained by international borders. This is of special concern for children, because they are intrinsically at greater risk, compared to adults. They have different opportunities for exposure, greater response to certain toxicants, and less empowerment to alter their environments. There is a growing awareness that adverse health effects in children can adversely affect a country's future productivity and well-being. Multiple government agencies, NGOs, and advocates are mobilizing to address these concerns. A sustained concerted effort will be needed to afford equitable and effective environmental health protection to the world's children, present and future.     

The costs of health damage and productivity losses attributable to cigarette smoking in Germany

Background: Smoking causes significant health damage and mayincur a significant economic burden to society. This study investigatesthe years of potential life lost, the direct medical costs andthe Indirect costs of cigarette smoking in Germany. Methods:Using the concept of attributable risks and the prevalence-basedapproach, smoking-attributable mortality and morbidity werecalculated for 1993. Neoplasms, cardiovascular diseases, respiratorydiseases, perinatal diseases and burn deaths were considered.Attributable risks stem from the literature and were processedin an epidemiological model. Costs were estimated from a societalperspective. Direct costs were mainly calculated based on routineutilization and expenditure statistics and indirect costs werecalculated according to the human capital approach. Results:Twenty-two percent of all male and 5% of all female deaths aswell as 1.5 million years of potential life lost were attributableto smoking. The costs of acute hospital care, in-patient rehabilitationcare, ambulatory care and prescribed drugs were 9.3 billionDEM, of mortality were 8.2 billion DEM and costs due to work-lossdays and early retirement were 16.4 billion DEM (discount rate3%). The total costs added up to 33.8 billion DEM, 415 DEM perinhabitant or 1,599 DEM per current smoker. Sensitivity analysesshowed that including the productivity loss of unpaid work leadsto a strong increase of indirect costs. Conclusions: This studyprovides a conservative estimate of the costs of smoking inGermany. The magnitude is considered sufficient reason to callfor stronger support of cost-effective, smoke-cessation measuresand of anti-smoking policy.     

The impact of the European Environment and Health Process on UK environment and health policy, plans and practice: what difference has it made?

The European Environment and Health Process (EEHP), led by theWorld Health Organization (WHO) Regional Office for Europe,aims to support WHO Member States as they plan and implementnational and international environment and health policies.An evaluation of the impact of the EEHP in the UK was conductedin preparation for the fourth Ministerial Conference on Environmentand Health in Budapest, 2004. The evaluation identified a numberof impacts and influences of the EEHP. This concluded that theprocess had only a marginal direct influence on policy withinthe UK. However, it was also concluded that the process hadresulted in several indirect influences, including better cooperationbetween government departments, greater awareness of environmentand health issues from an international perspective, and a higherpolitical profile of environment and health issues. A few outcomesof the EEHP also appear to have been taken into account in somenational and local policy documents. The National EnvironmentalHealth Action Plan, which was produced as a direct result ofthe EEHP, appears to have had little direct impact in the UK,probably because of the lack of an implementation process andindicators, and because it was superseded by other policy initiativesrelatively soon after publication. A need for better coordinationand promotion of the EEHP amongst stakeholders responsible forenvironment and health policy areas was also identified.     

Lessons for health strategies in Europe: The evaluation of a national health strategy in England

Objectives: To determine the impact of the national health strategyfor England, ‘Health of the Nation’ (HOTN) at thelocal level; the mechanisms by which this was achieved; andto provide lessons for the new strategy, ‘Saving lives:our healthier nation’. Design: Case studies. Semi-structuredInterviews with key actors across a range of organisations (n=133),analysis of documents (n=189), and analysis of expenditure forthe period 1991/1992 – 1996/1997. Setting: Eight randomlyselected English health authorities. Main outcome measures:Perceptions and documentary evidence of the impact of HOTN onlocal policy and changes In expenditure. Results: Three modelsof implementation were Identified: strategies based directlyon HOTN; HOTN plus additional elements (‘HOTN plus’);and strategies under another label such as healthy cities orurban regeneration. There was clear commitment to Intersectoralwork and some support for joint appointments of directors ofpublic health by health and local authorities. HOTN was seenas failing to address underlying determinants of health, reducingcredibility with key partners. Views were divided on whetherto adopt a population- or disease-based model. Consistency incentral government policies and communication of the strategywere criticised. HOTN was universally perceived as increasinghealth promotion activities, particularly in the key areas.HOTN received few mentions in corporate contracts and generalpractice reports. Expenditure on health promotion activitiesIncreased slightly then declined, and HOTN appears to have hadonly limited influence on resource allocation. Conclusions:Central government, In England, should enable rather than prescribestrategy implementation. It should ensure appropriate structuresare in place and that national polices are consistent with thestrategy. There is a debate about where the responsibility forhealth strategy should lie, whether with the NHS or local authorities.The new strategy should address different audiences: local government;the NHS; the voluntary sector; the private sector; and the public.One model is the matrix approach of the European Commissionhealth promotion programme. HOTN failed to engage three groups:the public, primary care, and the private sector. This studyhas important implications for the monitoring of the new strategy.It needs to be firmly embedded in the work of those who mustimplement it. It should be incorporated into the NHS performancemanagement framework. The current financial reporting mechanismspreclude monitoring expenditure on a health strategy. Ring-fencingsome resources for the new strategy should be considered, ifonly to give it the high priority it requires. This study, bothin terms of the methods used to evaluate the strategy and thelessons learned, could be used by other European countries developingand evaluating their own health strategies.     

Bullying and symptoms among school-aged children: international comparative cross sectional study in 28 countries

BACKGROUND: There have been no large-scale international comparisons on bullying and health among adolescents. This study examined the association between bullying and physical and psychological symptoms among adolescents in 28 countries. METHODS: This international cross-sectional survey included 123,227 students 11, 13 and 15 years of age from a nationally representative sample of schools in 28 countries in Europe and North America in 1997-98.The main outcome measures were physical and psychological symptoms. RESULTS: The proportion of students being bullied varied enormously across countries. The lowest prevalence was observed among girls in Sweden (6.3%, 95% CI: 5.2-7.4), the highest among boys in Lithuania (41.4%, 95% CI 39.4-43.5). The risk of high symptom load increased with increasing exposure to bullying in all countries. In pooled analyses, with sex stratified multilevel logistic models adjusted for age, family affluence and country the odds ratios for symptoms among students who were bullied weekly ranged from 1.83 (95% CI 1.70-1.97) to 2.11 (95% CI 1.95-2.29) for physical symptoms (headache, stomach ache, backache, dizziness) and from 1.67 (95% CI 1.55-1.78) to 7.47 (95% CI 6.87-8.13) for psychological symptoms (bad temper, feeling nervous, feeling low, difficulties in getting to sleep, morning tiredness, feeling left out, loneliness, helplessness). CONCLUSION: There was a consistent, strong and graded association between bullying and each of 12 physical and psychological symptoms among adolescents in all 28 countries.     

Selective international migration by social position, health behaviour and personality

BACKGROUND: Immigrants is an important minority in many countries, but little is known how they are self-selected. We analysed differences in psycho-social and health behavioural factors between international migrants and non-migrants prior to migration in a large cohort of Finnish twins. METHODS: A questionnaire was sent to Finnish twins in 1975 (response rate 89%, N = 26555 twin individuals). Follow-up data on migration and mortality were derived from population registries in Finland and Sweden up to 31 March 2002. In 1998, another questionnaire was sent to Finnish twins migrated to Sweden and their co-twins (response rate 71%, N = 1534 twin individuals). The data were analysed using Cox and conditional logistic regression models. RESULTS: Life dissatisfaction, higher alcohol use and smoking at baseline predicted future migration. In men additionally, unemployment, neuroticism and extroversion increased the probability to migrate. Similar associations were found for alcohol use in men and smoking in men and women within twin pairs discordant for migration. Twins also reported retrospectively that prior to migration the migrated twin had been less satisfied with his/her educational institution or job and was generally less satisfied with life, used more alcohol (men) and smoked more (women) than the co-twin stayed in Finland. CONCLUSION: Migrants are self-selected by health behavioural and personality factors, which may compromise their health. The special requirements of migrants should be recognized in health care.     

Socioeconomic status and transitions in status in old age in relation to limiting long-term illness measured at the 1991 Census: Results from the UK Longitudinal Study

Background: In the light of increasing interest in health inequalities,this paper aims to assess I) whether material deprivation inlate middle age and early old age is associated with greaterrisk of limiting long-term illness 20 years later and ii) whetherdeterioration in socioeconomic status during the first 10 yearscarries a higher risk than remaining in a higher status. Methods:The Longitudinal Study comprised a 1% sample of people registeredon the 1971 Census in England and Wales; data from successivecensuses are linked with vital events such as deaths. The subjectswere 23,320 people aged 55–74 years in 1971 and livingin the community in 1971, 1981 and 1991. Logistic regressionwas used to perform the analyses. Results: The relative riskof having a limiting long-term illness 20 years later for peoplein rented accommodation without a car at age 55–64 yearswas 1.2 compared to those in owner-occupied accommodation witha car. For those aged 65–74 years in 1971 the excess riskwas 9%. Moving out of owner occupation between 1971 and 1981and losing access to a car were associated with excess risksimilar to that for people already disadvantaged in 1971. Thus,socioeconomic circumstances In late middle and early old ageand deterioration in such circumstances after age 55 years,are associated with limiting long-term illness among peoplewho have survived in the community until at least age 75 years.Conclusion: Although health selection cannot be ruled out, itappears that health inequalities do not completely disappearin very old age.     

Cost of Diagnosing and Treating Cognitive Complaints: One-year Cost-evaluation Study in a Patient Cohort from a Slovenian Memory Clinic

IntroductionDementias present a global health challenge and give rise to significant economic costs. This study aims to evaluate the economic impact of one-year outpatient healthcare, nursing home, and formal and informal home help costs for all patients referred to the Centre for Cognitive Impairments at the Department of Neurology, Ljubljana University Medical Centre, Slovenia.MethodsData was acquired retrospectively from physicians’ records and the costs for 2015 were calculated. Total costs were estimated by means of a bottom-up calculation of outpatient visits, diagnostic examinations and anti-dementia medication. In a subgroup of 120 patients with dementia, the Resource Utilization in Dementia questionnaire was used to estimate formal and informal care costs.ResultsA total of 720 patients visited the memory clinic in 2015. Diagnosis at first visit was subjective cognitive or mild cognitive impairment (SCI/ MCI) for 322 patients, dementia for 258 patients, and psychiatric or other disorders for 140 patients. The average annual cost per patient was EUR 578. It was highest for patients with dementia (EUR 751), EUR 550 for patients with SCI/MCI, and lowest for patients with psychiatric and other disorders (EUR 324). Monthly informal and social care costs were between EUR 1,037 and EUR 3,369, depending on the methodology used.ConclusionThe cost of diagnosing a cognitive disorder depends on how extensive the diagnosis is. With an estimated prevalence of 34,137 persons with dementia in Slovenia, basic diagnostic investigations incur costs of approximately EUR 7 million. Direct medical costs represent a smaller portion of total dementia costs; this is because annual costs for formal and informal home help are estimated at EUR 265 million and nursing home placements at EUR 105 million.     

European training in public health: A practical experience

Development of public health in Europe requires the human resourcesnecessary for planning and managing programmes with a European,intersectoral and multidisciplinary approach, based on the ‘healthfor all’ strategy. In this paper the European TrainingConsortium in Public Health (ETC-PH) presents the experienceof 4 years of developing educational activities and materialwith these approaches. Participants from different countriesand 5 institutions concerned with training in public healthhave been involved. Evaluation is positive both for studentsand teachers and an ETC network and project register have beencreated as a way for communication to continue and for the consortiumto offer ongoing support to all participants.     

Should equity in health be target number 1?

Policy measures to reduce socioeconomic health differences (SEHD)must be preceded by an analysis of the possibilities and desirabilityof a reduction. This paper argues that it is necessary to pursueequality in health, conceived as equal opportunities to achievehealth. This principle is justified as part of the principleof maximizing individual freedom of choice, and requires thateveryone has the opportunity to be as healthy as possible. Bymeans of this principle a distinction can be made between unjust,unavoidable, and acceptable health inequalities. The determinantsof SEHD which lead to inequalities considered unjust must besubject to policy. These are living conditions (physical andsocial environment and health care) and conditions of choice(e.g. the knowledge of an individual about the health risksof a certain behaviour). Even if SEHD are considered inequities,sometimes conflicting interests will make it difficult to proposea health policy to redress these inequities. These are partlythe consequence of the intersectoral character of a policy aimedat equality of opportunities to attain health, in which theimportance of health has to be weighed against other goals.Moreover the impact of such a policy on the individual freechoice has to be critically weighed. Finally in the contextof health care policy, conflicts between the principle of equalityand maximizing health can be expected.     

Central issues in future research and policy for chronic diseases

In our ageing societies, with effective health care systems,more and more people will live till old age. It is an achievementof which we can be proud. However, it has implications for thefuture demand for health care services and financial consequencesthat need the attention of policy makers. It also has consequencesfor the main health care problems in future populations thatwill need the attention of the medical profession. These centralissues for future policy at the level of the individual patientand of the population raise questions that need to be addressedin research today. Using a computer simulation model, PREVENT,some of these issues are examined. It is shown that even withextensive preventive interventions absolute numbers of elderlypatients with chronic diseases will increase. In fact, effectiveprevention of mortality in middle-age will exacerbate this effect.Most of the current research on risk factors or clinical trialsdo not include elderly patients which greatly complicates cost-effectivenessanalyses or guidelines for both preventive and curative services.Policy measures will need to take into account the rise in demandand the shift towards more elderly patients. Research needsto shift attention to avoiding or averting disabilities andincreasing the quality of life.     

Interventions to reduce socioeconomic health differences: A review of the international literature

The objective of this study was to review information on evaluatedinterventions to reduce socioeconomic health differences (SEHD)and analyse studies to identify possible conditions for success.The analysed interventions were from published and unpublishedsources. They were evaluated in terms of socioeconomic healthoutcomes. Ninety-eight publications on actual interventionsto reduce SEHD and 31 so-called ‘grey literature’interventions were identified. Many of the interventions describedare reported to be effective. Many of the local experimentalinterventions, however, were not formally evaluated. Structuralmeasures appear to be effective most often, but cannot be takento affect all determinants. Interventions often Involve healtheducation. This, however, only appears to be successful if providinginformation is combined with personal support or structuralmeasures. Many very creative interventions to reduce SEHD havebeen reported. Several appear to be effective, but all addressonly a small aspect of health inequalities. Regrettably thelack of standardized measures and a common methodology hamperour ability to integrate and compare the results. However, allthe studies show that there is room for improvement in our existinghealth policies to reach everyone in our population to the samedegree of effectiveness.     

Public health management: Time for a new start?

One of the themes of health care reform Is a renewed focus onhealth rather than health care. The role of the purchaser isdirected towards health gain rather than merely the maintenanceof health care services. This goal can only be achieved if publichealth specialists and health services managers work togetherand share skills. There is a need for public health physicians,non-clinical public health specialists and health service managersto find an intellectual focus for joint working since theirrespective skills are complementary. Whereas public health haslooked outwards towards the health needs of the population,health care management has focused inwards on the organizationof health services. The concept of public health managementoffers a unifying focus. It centres on the mobilization of society'sresources, including those of the health service sector, toimprove the health of populations through whatever means ismost appropriate. Public health has suffered from a tensionbetween knowledge and action. Public health management seeksto resolve this tension. The paper explores the concept of publichealth management, analyses the skills required for its successfulpractice and considers the training programmes required to developpublic health managers. The authors call on European organizationsto champion the concept of public health management.     

Is a global rural and remote health research agenda desirable or is context supreme?

Objective: This paper proposes that there is value in international comparison of rural and remote health‐care service delivery models because of practical reasons – to find ideas, models and lessons to address ‘local’ delivery challenges; and for theoretical reasons – to derive a conceptual framework for international comparison. Methods: Literature review and commentary. Findings: There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care. Conclusions: The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.     

Cost of diabetes and its complications in Thailand: a complete picture of economic burden

Diabetes is a common metabolic disorder with increasing burden in Thailand. The chronic nature along with associated complications makes the disease very costly. In Thailand, there exist some studies on cost of diabetes; however, those studies estimated the cost either from provider or from patient perspective. In order to capture the complete picture of economic burden caused by diabetes, using prevalence-based approach; the present study estimated the cost of illness of diabetes from societal perspective, the broadest viewpoint covering all costs irrespective of who incur them. Data were collected from 475 randomly selected diabetic patients who received treatment from Waritchaphum hospital in Sakhon Nakhon province of Thailand during 2007-2008 with a response rate of 98%. A micro-costing approach was used to calculate the cost. The direct medical cost was calculated by multiplying the quantity of medical services consumed by their unit costs while indirect cost was calculated by using human capital approach. The total cost of illness of diabetes for 475 study participants was estimated as USD 418,696 for the financial year 2008 (1 USD = 32 THB). Of this, 23% was direct medical cost, 40% was direct non-medical cost and 37% was indirect cost. The average cost of illness per diabetic patient was USD 881.47 in 2008 which was 21% of per capita gross domestic product of Thailand. Existence of complications increased the cost substantially. Cost of informal care contributed 28% of total cost of illness of diabetes. Therefore, the disease not only affected the individual but also the family members, friends and neighbours. The economic and social burden of the disease therefore emphasises the need for initiatives to prevent the disease prevalence and counselling to the diabetic patients to prevent the progression of the disease and its devastating complications.     

Cost containment and the right to health care

This article addresses the question of how cost containmentprogrammes affect the right to health care in The Netherlands.A distinction is made between three different dimensions ofthe right to health care: health care entitlements, need assessmentand enforceability. The analysis starts with a discussion ofentitlements in social and private health insurance and a briefoverview of how decisions on entitlements are made. Next, itis shown how the search for cost containment has influencedhealth care entitlements in Dutch health care (e.g. criticalscreening of entitlements) and has resulted in a need for morestringent guidelines for need assessment to use health careresources more efficiently. The growing gap between the growthrates in health care demand and the resources for health carepoints to the creation of enforceability problems in healthcare (waiting lists). The final section discusses the questionof whether Dutch health care is moving towards a two-tier system.Throughout the analysis attention is given to the politicaldimension of the debate on health care entitlements, need assessmentand the enforceability of entitlements.     

Lack of training as a central barrier to the promotion of smoking cessation: a survey among general practitioners in Germany

BACKGROUND: General practitioners (GPs) can contribute substantially to the promotion of smoking cessation in the general population. However, engagement of GPs in helping their patients to quit remains very limited in many countries, including Germany. Therefore, new strategies to foster implementation of evidence-based methods in smoking cessation assistance have to be identified, and data for current practice of and barriers against smoking cessation promotion in general practice are needed. METHODS: A cross-sectional survey among all 657 general practitioners practising in the Rhein-Neckar Region of Germany was conducted in spring 2002 using a postal questionnaire (response rate 48%). RESULTS: The majority (54%) of GPs reported having treated less than 10 patients for smoking cessation (by any means including mere advice to quit) within the last three months, 23% of GPs never received any education or training in smoking cessation promotion, and only one-third of GPs rated their training as adequate. The factor most strongly associated with low activity in smoking cessation promotion (defined as having treated less than 10 patients within the last three months) was perceived lack of training (odds ratio 2.70, 95% confidence interval 1.68 - 4.32), followed by perceived lack of demonstration material (2.10, 1.31 - 3.39) and perceived lack of time (1.65, 1.02 - 2.66). Furthermore, there was a clear dose-response relationship between the time spent on training and the activity in smoking cessation promotion. CONCLUSION: Adequate training may be a key factor to enhance engagement of general practitioners in the promotion of smoking cessation.