Globalization,global health,and access to healthcare

It is now commonly realized that the globalization of the world economy is shaping the patterns of global health, and that associated morbidity and mortality is affecting countries' ability to achieve economic growth. The globalization of public health has important implications for access to essential healthcare. The rise of inequalities among and within countries negatively affects access to healthcare. Poor people use healthcare services less frequently when sick than do the rich. The negative impact of globalization on access to healthcare is particularly well demonstrated in countries of transitional economies. No longer protected by a centralized health sector that provided free universal access to services for everyone, large segments of the populations in the transition period found themselves denied even the most basic medical services. Only countries where regulatory institutions are strong, domestic markets are competitive and social safety nets are in place, have a good chance to enjoy the health benefits of globalization.     

Strengthening eHealth Systems to Support Universal Health Coverage in sub-Saharan Africa

The aim of universal health coverage (UHC) is to ensure that all individuals in a country have access to quality healthcare services and do not suffer financial hardship in using these services. However, progress toward attaining UHC has been slow, particularly in sub-Saharan Africa. The use of information and communication technologies for healthcare, known as eHealth, can facilitate access to quality healthcare at minimal cost. eHealth systems also provide the information needed to monitor progress toward UHC. However, in most countries, eHealth systems are sometimes non-functional and do not serve programmatic purposes. Therefore, it is crucial to implement strategies to strengthen eHealth systems to support UHC. This perspective piece proposes a conceptual framework for strengthening eHealth systems to attain UHC goals and to help guide UHC and eHealth strategy development.     

Development of voluntary private health insurance in Nordic countries – An exploratory study on country-specific contextual factors

The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors.     

The effects of neoliberal policies on access to healthcare for people with disabilities

Neoliberal reforms lead to deep changes in healthcare systems around the world, on account of their emphasis on free market rather than the right to health. People with disabilities can be particularly disadvantaged by such reforms, due to their increased healthcare needs and lower socioeconomic status. In this article, we analyse the impacts of neoliberal reforms on access to healthcare for disabled people. This article is based on a critical analytical review of the literature and on two case studies, Chile and Greece. Chile was among the first countries to introduce neoliberal reforms in the health sector, which led to health inequalities and stratification of healthcare services. Greece is one of the most recent examples of countries that have carried out extensive changes in healthcare, which have resulted in a deterioration of the quality of healthcare services. Through a review of the policies performed in these two countries, we propose that the pathways that affect access to healthcare for disabled people include: a) Policies directly or indirectly targeting healthcare, affecting the entire population, including disabled people; and b) Policies affecting socioeconomic determinants, directly or indirectly targeting disabled people, and indirectly impacting access to healthcare. The power differentials produced through neoliberal policies that focus on economic rather than human rights indicators, can lead to a category of disempowered people, whose health needs are subordinated to the markets. The effects of this range from catastrophic out-of-pocket payments to compromised access to healthcare. Neoliberal reforms can be seen as a form of structural violence, disproportionately affecting the most vulnerable parts of the population – such as people with disabilities – and curtailing access to basic rights, such as healthcare.     

Farmers' occupational health care--worldwide

This review will summarize the current state of preventive health care systems for farmers in the world. It is obvious that well-organized occupational health care systems for farmers occur sporadically in only a few countries, and generally are in the initial stages of development. Large cooperative farms and plantations may have industrialized occupational health care. In some countries in Europe, e.g., France and Austria, farmers' organizations may include a certain amount of health and safety activity within their social insurance systems for farmers. Moreso than in other places, the Scandinavian countries have tried different approaches to provide comprehensive health services among farmers. Regardless of the kind of system, it is obvious from experiences worldwide that agriculture is a risky occupation and farmers are exposed to numerous hazards which may result in injuries, work-related diseases, and death. It is promising to note an increased interest in this situation from many parts of the world.     

Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples

Objective : Given the high prevalence of chronic disease, it is of concern that access to and sustained engagement with primary healthcare services by Aboriginal and Torres Strait Islander Australians is often far lower than would be expected. This study sought to explore ways in which relationships can support sustained engagement with healthcare services. Methods: Semi‐structured interviews were conducted with 126 Aboriginal and Torres Strait Islander participants with and without chronic disease and 97 Aboriginal and Torres Strait Islander and non‐Indigenous healthcare providers, healthcare service managers or administrative staff. Results : Our findings indicate that when faced with acute health issues, Aboriginal and Torres Strait Islander participants did prioritise care, provided that the service was both physically and emotionally welcoming. Trustworthiness of healthcare providers and strong relationships with patients were the most important factors for encouraging sustained engagement overtime. Conclusions : Responsibility for sustaining relationships does not rest solely with Aboriginal and Torres Strait Islander patients. Rather, healthcare providers need to commit to the process of building and maintaining relationships. Implications : First and foremost healthcare providers should take time to establish and then maintain relationships. Healthcare services can also contribute by ensuring facilities are welcoming for Aboriginal and Torres Strait Islander peoples.     

Suboptimal provision of preventive healthcare due to expected enrollee turnover among private insurers

Many preventive healthcare procedures are widely recognized as cost-effective but have relatively low utilization rates in the US. Because preventive care is a present-period investment with a future-period expected financial return, enrollee turnover among private insurers lowers the expected return of this investment. In this paper, I present a simple theoretical model to illustrate the suboptimal provision of preventive healthcare that results from insurers ‘free riding’ off of the provision from others. I also provide an empirical test of this hypothesis using data from the Community Tracking Study's Household Survey. I use lagged market-level measures of employment-induced insurer turnover to identify variation in insurers' expectations and test for the effect of turnover on several different measures of medical utilization. As expected, I find that turnover has a significantly negative effect on the utilization of preventive services and has no effect on the utilization of acute services used as a control. Copyright © 2009 John Wiley & Sons, Ltd.     

What is driving people’s dissatisfaction with their own health care in 17 Latin American countries?

Background A number of expert reports have pointed to serious problems with health care in many Latin American countries and argued the need to reform and improve health‐care systems. In addition, the Ministers of Health of the Americas have stated that health systems should be accountable to citizens. Objective This paper examines, in each of 17 Latin American countries, public dissatisfaction with the health care to which people have access, the proportion of people reporting problems with access to and the cost of health care and the factors that are most important in driving public dissatisfaction. Methods Data are drawn from a 2007 Latinobarómetro survey of 19 212 adults interviewed face‐to‐face in 17 Latin American countries. Results The proportion of people expressing dissatisfaction with their health care varies a great deal by country, as do the proportions reporting problems with access to and the cost of health care. Problems with access to care seem to matter most in trying to explain public dissatisfaction with their health care. More traditional measures of health outcomes and resources seem to matter less as drivers of dissatisfaction. Conclusions For governments trying to improve their citizens’ satisfaction with the health care they receive, the highest priority would be improving people’s basic access to health‐care services. Also, it appears that democratic governments are seen as being more responsive to the public’s needs in health care.     

加强农村卫生服务体系建设 促进人人享有基本卫生保健

建立国家基本卫生制度、实现人人享有基本卫生保健是国际社会＂全民健康覆盖＂目标的具体体现。过去几十年,江苏省农村卫生服务体系得到了较好发展,基本建立具有较高可及性的农村服务组织网络,为实现农村居民人人享有基本卫生保健打下了良好的基础,同时还存在诸多亟待解决的问题。为此提出建议：明确政府健康责任,改革卫生投入机制;优化卫生服务体系布局,提高高质量卫生服务的可及性;加强基层卫生人才队伍建设,提高基本卫生服务质量;完善薪酬分配制度,调动卫生人员积极性。     

Quality Improvement in Healthcare Delivery Utilizing the Patient-Centered Medical Home Model

Despite the fact that the United States dedicates so much of its resources to healthcare, the current healthcare delivery system still faces significant quality challenges. The lack of effective communication and coordination of care services across the continuum of care poses disadvantages for those requiring long-term management of their chronic conditions. This is why the new transformation in healthcare known as the patient-centered medical home (PCMH) can help restore confidence in our population that the healthcare services they receive is of the utmost quality and will effectively enhance their quality of life. Healthcare using the PCMH model is delivered with the patient at the center of the transformation and by reinvigorating primary care. The PCMH model strives to deliver effective quality care while attempting to reduce costs. In order to relieve some of our healthcare system distresses, organizations can modify their delivery of care to be patient centered. Enhanced coordination of services, better provider access, self-management, and a team-based approach to care represent some of the key principles of the PCMH model. Patients that can most benefit are those that require long-term management of their conditions such as chronic disease and behavioral health patient populations. The PCMH is a feasible option for delivery reform as pilot studies have documented successful outcomes. Controversy about the lack of a medical neighborhood has created concern about the overall sustainability of the medical home. The medical home can stand independently and continuously provide enhanced care services as a movement toward higher quality care while organizations and government policy assess what types of incentives to put into place for the full collaboration and coordination of care in the healthcare system.     

Hospitalization among migrants in Italy: Access to health care as an opportunity for integration and inclusion

This paper analyzes migrant access to health care by comparing hospitalizations of native and immigrant population with respect the Tuscany Region (Italy). In the analyses, a critical gap both for legal and undocumented migrant population is highlighted. Indeed, we found some key differences between the migrant and native populations related to the use of specific hospital services in Tuscany and, indirectly, of community and primary care services. Moreover, especially for undocumented migrants, hospitals seem to be the only point of access to the health‐care system for migrant populations. The results suggest that the Italian health‐care system is unable to ensure an equitable access to health services. In this context, maternity care could be a key point of access to the welfare system that allows participation in the health system not only for mothers but also for all migrant family members.     

What Is Next for Pharmacoeconomics and Outcomes Research in Asia?

OBJECTIVES: Pharmacoeconomics and outcomes research have the potential for rapid adoption in the Asia Pacific region. Nevertheless, the region is characterized by great diversity in social and economic development, ethnicity, population size, health-care system, culture, language, and religion. Thus, the rate of adoption is also quite diverse across the region. METHODS: Among the countries reviewed in this article, governments take varying levels of interest in applying this research in health policy decisions. For example, some countries have already implemented systems that require pharmacoeconomic studies as one component of a new pharmaceutical product's approval for reimbursement, whereas others recommend such data but do not require it in policy and medical decision making. The literature in the countries reviewed is actually quite robust given the early stages of development of this field in most countries. The academic community has members trained in this field of research in all the countries reviewed and some universities have established departments whereas others have just introduced a few classes in the area. RESULTS: At the moment, pharmacoeconomics and outcomes research are being conducted mainly by academics. In addition, some pharmaceutical researchers are active and pharmaceutical companies are currently preparing to conduct more of this research as part of their strategy for Asian drug development. CONCLUSIONS: Prospects for future growth and development in this field are quite good in Asia as rapid healthcare inflation, increasing rates of chronic conditions and aging population, and increasing technology diffusion will underpin the need for greater awareness of the need to incorporate economic efficiency into the health-care systems.     

Do social inequalities exist in terms of the prevention,diagnosis, treatment,control and monitoring of diabetes? A systematic review

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.     

Quality-based purchasing in health care

Quality-based purchasing is a growing trend that seeks to improve healthcare quality through the purchaser-provider relationship. This article provides a unifying conceptual framework, presents examples of the purchaser-provider relationship in countries at different income levels, and identifies important supporting mechanisms for quality-based purchasing. As countries become wealthier, a higher proportion of healthcare spending is channeled through pooled arrangements, allowing for greater involvement of purchasers in promoting the quality of service provision. Global and line item budgets are the most common type of provider payment system in low and middle-income countries. In these countries, improving public hospital performance through contracting and incentives is a key issue. In middle and high-income countries, there are several documented examples of governments contracting to private or non-governmental health care providers, resulting in higher perceived quality of care and lower delivery costs. Encouraging quality through employer purchasing arrangements has been promoted in several countries, particularly the United States. Community-based financing schemes are an increasingly common form of health financing in parts of sub-Saharan Africa and Asia, but these schemes still cover less than 10% of national populations in countries in which they are active. To date, there is little evidence of their impact on healthcare quality. The availability of information--concerning healthcare service provision and outcomes--determines the options for establishing and monitoring contract provisions and promoting quality. Regardless of the context, quality-based purchasing depends critically on informa-tion--reporting, monitoring, and providing useful information to healthcare consumers. In many low and middle-income countries, the lack of availability of information is the principal constraint on measuring performance, a critical component of quality-based purchasing.     

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries’ approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country’s culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.     

Health care utilization patterns of Russian-speaking immigrant women across age groups

The collapse of the Soviet Union in 1989 substantially increased the numbers of refugees and immigrants to the United States from the former Soviet Union. Little research has been conducted with this population although studies found that immigrant's access to health care services are based on patterns of utilization in their countries of origin. The purpose of this study was to learn about the experiences of immigrant women from three former Soviet Republics (Belarus, Russia, and Ukraine) with women's health care services. Three focus groups of women were formed; ages 20–30, 37–46, and 60 and above. A focus-group guide was used to learn about their health care experiences. These immigrant women did access health care services based on patterns of utilization in their countries of origin. Greater understanding of immigrant populations' cultural patterns of health care utilization is needed to improve access and delivery of health care services to these populations.     

Incentives for voluntary health insurance in a national health system: Evidence from Italy

ObjectivesThe paper evaluates the extent to which the government's policy to encourage the purchase of voluntary health insurance (VHI) may have led to income-related horizontal inequity in access to health care in a universal health care system (NHS).MethodsAd hoc tax return data for the universe of Italian taxpayers for years 2009-2016 are used to estimate the tax benefits granted to taxpayers who hold VHI, the redistributive impact, and the public budget effect. The income elasticity of tax benefits is estimated using tax return data and considering some taxpayers’ characteristics (income class, gender, age, and geographic area). Standard inequality indices are computed to assess income-related horizontal inequity in access to health care.ResultsTax incentives, especially those granted to employer-paid health insurance, have a sizeable impact on tax revenue and introduce into the Italian NHS significant income-related horizontal and vertical inequity in access to health care. The results suggest a distributional profile of tax incentives that is highly concentrated in favor of wealthier taxpayers.ConclusionOur analysis adds novel evidence that may contribute to the current debate on whether and to what extent countries in which all citizens have access to free healthcare and equal standards of healthcare services should subsidize VHI, especially when the coverage doubles the healthcare services provided by universal public insurance. We show that VHI reduces tax revenues and introduces disparities among citizens in terms of access to healthcare services.     

Health care financing and utilization of maternal health services in developing countries

BACKGROUND: The Millennium Development Goals call for a 75% reduction in maternal mortality between 1990 and 2015. Skilled birth attendance and emergency obstetric care, including Caesarean section, are two of the most important interventions to reduce maternal mortality. Although international pressure is rising to increase donor assistance for essential health services in developing countries, we know less about whether government or the private sector is more effective at financing these essential services in developing countries. METHODS: We conducted a cross-national analysis to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and Caesarean section in 42 low-income and lower-middle-income countries. We controlled for possible confounding effects of total per capita health spending and female literacy. FINDINGS: In multivariable analysis, adjusting for confounders, government health expenditure as a percentage of total health expenditure is significantly associated with utilization of skilled birth attendants (P = 0.05) and Caesarean section (P = 0.01) but not antenatal care. Total health expenditure is also significantly associated with utilization of skilled birth attendants (P < 0.01) and Caesarean section (P < 0.01). DISCUSSION: Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and Caesarean section. While government financing is associated with better access to some essential maternal health services, greater absolute levels of health spending will be required if developing countries are to achieve the Millennium Development Goal on maternal mortality.