Study on Equity and Efficiency of Health Resources and Services Based on Key Indicators in China

Background

This study aims to evaluate the dialectical relationship between equity and efficiency of health resource allocation and health service utilization in China.

Methods

We analyzed the inequity of health resource allocation and health service utilization based on concentration index (CI) and Gini coefficient. Data envelopment analysis (DEA) was used to evaluate the inefficiency of resource allocation and service utilization. Factor Analysis (FA) was used to determine input/output indicators.

Results

The CI of Health Institutions, Beds in Health Institutions, Health Professionals and Outpatient Visits were -0.116, -0.012, 0.038, and 0.111, respectively. Gini coefficient for the 31 provinces varied between 0.05 and 0.43; out of these 23 (742%) were observed to be technically efficient constituting the “best practice frontier”. The other 8 (25.8%) provinces were technically inefficient.

Conclusions

Health professionals and outpatient services are focused on higher income levels, while the Health Institutions and Beds in Health Institutions were concentrated on lower income levels. In China, a few provinces attained a basic balance in both equity and efficiency in terms of current health resource and service utilization, thus serving as a reference standard for other provinces.     

The choice between people: 'common sense' morality, and doctors

Kamm is concerned with explaining how "common sense" morality might be used in deciding about the distribution of scarce medical resources. Drawing an analogy between redirection of possible harms or threats and the allocation of health resources, she first explores how an ordinary moral agent, not a physician, might act. Using what Kamm calls the principle of irrelevant utilities (PIU), a moral agent might decide between contestants for a particular good based on "sobjectivism" (Sob), the author's term for a combination of the objective and subjective points of view. Kamm explores decision making using three versions of Sob that weigh interests and rights, equivalences, and aggregation of costs (losses). She concludes that, while ordinary moral agents functioning as social agents may act according to objective aggregated costs, physicians should be concerned with equivalents and individuals when allocating resources.     

Designing equitable antiretroviral allocation strategies in resource-constrained countries

Background

Recently, a global commitment has been made to expand access to antiretrovirals (ARVs) in the developing world. However, in many resource-constrained countries the number of individuals infected with HIV in need of treatment will far exceed the supply of ARVs, and only a limited number of health-care facilities (HCFs) will be available for ARV distribution. Deciding how to allocate the limited supply of ARVs among HCFs will be extremely difficult. Resource allocation decisions can be made on the basis of many epidemiological, ethical, or preferential treatment priority criteria.

Methods and Findings

Here we use operations research techniques, and we show how to determine the optimal strategy for allocating ARVs among HCFs in order to satisfy the equitable criterion that each individual infected with HIV has an equal chance of receiving ARVs. We present a novel spatial mathematical model that includes heterogeneity in treatment accessibility. We show how to use our theoretical framework, in conjunction with an equity objective function, to determine an optimal equitable allocation strategy (OEAS) for ARVs in resource-constrained regions. Our equity objective function enables us to apply the egalitarian principle of equity with respect to access to health care. We use data from the detailed ARV rollout plan designed by the government of South Africa to determine an OEAS for the province of KwaZulu–Natal. We determine the OEAS for KwaZulu–Natal, and we then compare this OEAS with two other ARV allocation strategies: (i) allocating ARVs only to Durban (the largest urban city in KwaZulu–Natal province) and (ii) allocating ARVs equally to all available HCFs. In addition, we compare the OEAS to the current allocation plan of the South African government (which is based upon allocating ARVs to 17 HCFs). We show that our OEAS significantly improves equity in treatment accessibility in comparison with these three ARV allocation strategies. We also quantify how the size of the catchment region surrounding each HCF, and the number of HCFs utilized for ARV distribution, alters the OEAS and the probability of achieving equity in treatment accessibility. We calculate that in order to achieve the greatest degree of treatment equity for individuals with HIV in KwaZulu–Natal, the ARVs should be allocated to 54 HCFs and each HCF should serve a catchment region of 40 to 60 km.

Conclusion

Our OEAS would substantially improve equality in treatment accessibility in comparison with other allocation strategies. Furthermore, our OEAS is extremely different from the currently planned strategy. We suggest that our novel methodology be used to design optimal ARV allocation strategies for resource-constrained countries.     

Predictores de mala salud autopercibida en una población de personas mayores

Introduction

Self-Rated Health is part of the comprehensive concept of Quality of Life and is a valid measurement of health status. The main objective of this study was to test the predictive value of some different variables on the poor Self-Rated Health among elders.

Material and methods

We performed a cross-sectional study on a sample consisting of 140 participants. Measurements: age, gender, level of education, environment, cognitive status, physical impairment, diseases, health perception and social support. The influence of the studied variables on the poor Self-Rated Health was performed with a logistic regression analysis and a ROC curve to establish the cut-off values for these variables with the best sensitivity and specificity to predict the poor Self-Rated Health.

Results

A poor Self-Rated Health was significantly associated with age, comorbidity, and the perception of poor functional social support, whereas no association was found with gender, environment and educational level.

Conclusions

Old age, the number of diagnosed diseases, and functional social support are Self-Rated Health risk factors, while the characteristics and repercussions of the diseases should not be considered.     

Need for primary health care: an objective indicator.

The allocation of resources for primary health care should be based on the community''s needs and not only on the workload of general practitioners. I therefore present an objective indicator that may be used to assess the need for primary health care.     

多需求鱼池定价问题

本文考虑了多需求下的鱼池定价问题．假设有m个鱼池可供投放鱼类种群,n个顾客需要使用鱼池,每个顾客有多个鱼类种群需要投放到至多m个鱼池中去．鱼池所有者根据顾客的需求和报价进行重新定价和最终分配,在满足部分顾客的全部需求下最大化其收益．文中考虑了两种定价机制-单一定价和按比例定价．并结合背包算法,在按比例定价情形下设计了具有对数竞争比的算法,最大化鱼池所有者的收益．     

Where medical science and human behaviour meet.

Although we may be wrong about the details, we should try to imagine what the future holds for hospital consultants. The days of the independent consultant in the same post for 30 years are over, and there will be a change from "the" consultant to a few tiers of senior staff. Patients will increasingly demand to see specialists, so more specialists will be needed. As patients and their advocates become better informed the traditional rationing of clinical care to patients in Britain, such as restricting access to specialists, cannot continue. There is a current trend for evidence based health care, but the idea that each element of medical practice can be dictated by systematic evidence based research will prove to be naïve--such research informs practice rather than dictates it. Science will continue to act as the guide to medical practice but specialists will not be turned into a set of logical operators running programs designed by health planners.     

江西省公立医院经济运行现状分析

调查分析江西省12所不同等级、不同地区公立医院2000—2007年的经济运行数据。结果发现,江西省12所公立医院8年来经济运行状况明显改善,发展趋势良好,但是仍然存在政府投入不足、收支结构不合理、“以药养医”现象严重、营利能力不强等突出问题。建议加大政府对公立医院的监管和财政补助力度,优化卫生资源配置,改革以药养医的经济运行机制,调整医药价格体系,提高医疗服务水平和效率。     

In Search of a Consistent Solution to Allocation of Joint Production

Three consistency problems are identified that arise when partitioning a product system with joint production according to an allocation key, such as revenue or mass of the joint products, namely: lacking consistency of rationales and procedures; lacking consistency of monetary, mass, and energy balances in the partitioned product systems; and lacking consistency of results across model resolution and classification of the intermediate flows. Different solutions to these consistency problems are described, including the attempt of ecoinvent to solve the third consistency problem with a system model that uses revenue allocation at the point of substitution. The problems with the different practical implementations are described. For each of the three consistency problems, a solution is proposed and combined into a single consistent solution. The consistency of rationales and procedures is ensured by asking only one question at a time and performing a separate allocation and calculation for each question. The problem of maintaining monetary, mass, and energy balances is solved by a generalized allocation correction. The identified problem with consistency of results across model resolution and classification is solved by redefining the point of substitution. It is described what consequences the solutions will have if their results are misused for decision making that will shift demand between products.     

Open-nucleus breeding strategies compared with population-wide positive assortative mating

Positive assortative mating (PAM) can enhance the additive genetic variance in a breeding population(BP). This increases the potential for gains in the production population (PP, selected subset of the BP) for recurrent selection programs in forest trees. The assortment of mates can be either: (1) by individual tree rank across the whole BP (PAM), or (2) trees of similar rank can be merged into larger hierarchical groups and then mated randomly within group ("open"-nucleus breeding,NB). The objective of this study was to compare PAM and NB in quantitative terms. The NB simulation model assumed two tiers (nucleus, main) with unrestricted migration between the tiers. Clonal tests were used to predict breeding values and test resources per mate were kept constant for all mates. Both gain and diversity were combined into a single selection criterion, "group-merit selection." Alternatives were compared over five breeding cycles by considering genetic gain and diversity in a selected PP established in a seed orchard. The assortment of mates in both alternatives enhanced additive variance and increased the additive effect in the BP, leading to additional gain in the PP. Gains generated under PAM always exceeded gains under NB. Thus, the main message from this study is that PAM in both the short- and long-term results in more gain at any target level of diversity in the PP (the breeder's target) than is achieved by the NB alternative. The optimum size of the nucleus varies with the desired level of seed orchard diversity. At lower target diversity, smaller nucleus sizes are favorable, while larger sizes result in more gain when seed orchard diversity is considered more important.     

Physical parameter-based allocation for the energy consumption of pyro-metallurgical system—a case study on nickel production in China

Purpose

The objectives of this study were to establish an allocation model for the energy consumption of pyro-metallurgical system based on the physical relationship between the input and output, apply the established model to nickel production in China and compare the difference between the allocation results derived from the established model and the traditional models.

Methods

The basic methodological idea of this study is that the energy input of a multi-output pyro-metallurgical process should be allocated according to how the energy input is consumed in the process. The energy consumption of pyro-metallurgical system was decomposed into different categories (e.g. energy absorption of chemical reaction and energy loss), and these categories were classified into two groups, i.e. the categories of energy consumption dependent on the product ratio (PRDE) and the categories of energy consumption independent on the product ratio (PRIE); then, the allocation basis for each category of energy consumption was determined through the physical relationship between the energy input and metal output. The allocation for the energy consumption of nickel production in China was carried out; the system boundary includes two sub-systems (i.e. Ni–Cu coproduction system and Ni refining system), and the energy consumption of the coproduction system should be allocated; the basic data required by the allocation model and the compilation of LCI were mainly obtained from literature.

Results and discussion

The energy consumption of the processes of mining, drying, converting and floating-grinding belongs to PRIE following the principle of mass-based allocation, and the corresponding allocation factors are 64, 64, 69 and 69 %, respectively. The categories of energy consumption involved in the smelting process (the key process for demonstrating the allocation model) include both PRIE and PRDE, and the aggregated allocation factor was calculated as 56 %. The allocation result derived from the established model is lower than the results derived from the mass-based model and the market value-based model, because that, through the desulphurization reactions that occurred in the smelting process, the chemical states of copper and nickel are transformed from copper pyrite (CuFeS₂) and nicopyrite ((Fe,Ni)₉S₈) into cuprous sulphide (Cu₂S) and nickel sulphide (Ni₃S₂), and copper compound releases more sulphur atoms than nickel compound. When analyzing a single pyro-metallurgical process, the result of allocation is sensitive to basis selection; however, when comparing two or more pyro-metallurgical processes, the comparison result of allocation is relatively insensitive to basis selection.

Conclusions

The energy input of pyro-metallurgical system is consumed in different physical-chemical ways; the decomposition of energy consumption is significant for choosing allocation bases; the basis of mass can only be used for the allocation of PRIE, and choosing the same allocation basis for different cases without a systematic analysis will be inappropriate. The requirement of some nontraditional extra inventory data is the major limitation of the established model. This study mainly focused on how nickel production system consumes the energy input, and the energy consumption patterns of other production systems should be taken into account in future studies.

     

A Sequential Approach to Risk Assessment of Transgenic Plants Expressing Protease Inhibitors: Effects on Nontarget Herbivorous Insects

Protease inhibitors expressed in transgenic plants can provide enhanced levels of resistance to important pest species. A sequential approach for testing the effects of protease inhibitor-expressing crops on nontarget herbivorous insects has been developed. The approach consists of five tiers. The first two tiers comprise the selection phase. In tier one, field surveys are used to characterise the nontarget invertebrate fauna of a crop. In tier 2, histochemical assays are used to identify the subset of herbivores with a particular class of digestive proteolytic enzymes. In the assessment phase a combination of laboratory worst-case scenario studies (tier 3) and controlled environment or small-scale field trials (tier 4) are used to evaluate the impact of the protease inhibitor-expressing plants on the selected nontarget species. In the final tier, field trials are used to compare the relative effect of transgenic plants and current management practices, such as pesticide use, on selected species. The first four tiers of the approach are described using potatoes expressing cystatins, a family of cysteine proteinase inhibitors, as an example. Although the plants have enhanced levels of resistance to potato cyst nematodes (PCN), Globodera pallida and Globodera rostochiensis, the results establish that they have negligible impact on the nontarget herbivorous insect, Eupteryx aurata.     

Dynamic energy budget models with size-dependent hazard rates

We formulate and analyze two dynamic energy budget models, a net assimilation model with constant allocation strategy and a net production model with a 2-stage allocation strategy, with the objective of determining strategies that maximize the expected lifetime reproductive energy. The per capita death rate depends on the organisms size, as for example when the main cause of death is predation. In the analysis of the net production model, the size at maturity is calculated along with the probability of reaching that size. We show that a small probability of survival to maturity is incompatible with the simple assumption of an exponential survival probability. We demonstrate that when the hazard rate is significantly greater for small individuals than large ones, it is possible for the optimum strategy to be for an individual to grow to a large size in spite of an arbitrarily small probability of survival to maturity. Numerical simulations indicate how the optimal allocation strategies depend on the parameter values.     

The need for co-product allocation in the life cycle assessment of agricultural systems—is “biophysical” allocation progress?

Purpose

Several new “biophysical” co-product allocation methodologies have been developed for LCA studies of agricultural systems based on proposed physical or causal relationships between inputs and outputs (i.e. co-products). These methodologies are thus meant to be preferable to established allocation methodologies such as economic allocation under the ISO 14044 standard. The aim here was to examine whether these methodologies really represent underlying physical relationships between the material and energy flows and the co-products in such systems, and hence are of value.

Methods

Two key components of agricultural LCAs which involve co-product allocation were used to provide examples of the methodological challenges which arise from adopting biophysical allocation in agricultural LCA: (1) the crop production chain and (2) the multiple co-products produced by animals. The actual “causal” relationships in these two systems were illustrated, the energy flows within them detailed, and the existing biophysical allocation methods, as found in literature, were critically evaluated in the context of such relationships.

Results and discussion

The premise of many biophysical allocation methodologies has been to define relationships which describe how the energy input to agricultural systems is partitioned between co-products. However, we described why none of the functional outputs from animal or crop production can be considered independently from the rest on the basis of the inputs to the system. Using the example of manure in livestock systems, we also showed why biophysical allocation methodologies are still sensitive to whether a system output has economic value or not. This sensitivity is a longstanding criticism of economic allocation which is not resolved by adopting a biophysical approach.

Conclusions

The biophysical allocation methodologies for various aspects of agricultural systems proposed to date have not adequately explained how the physical parameters chosen in each case represent causal physical mechanisms in these systems. Allocation methodologies which are based on shared (but not causal) physical properties between co-products are not preferable to allocation based on non-physical properties within the ISO hierarchy on allocation methodologies and should not be presented as such.

     

Tuition fees for residents: one physician's perspective

Although the education, expertise and guidance of Canada''s academic physicians cannot be overlooked, individual universities appear to see tuition fees for residents as an easy source of much needed revenue. If tuition should "rise to market levels," perhaps residents'' wages should similarly rise to reflect the amount of training received, skills required, responsibilities discharged and time expended. Unfortunately, tuition fees will be an area of contention for some time. Support of provincial resident associations and medical societies may lend both moral and, possibly, financial support to future members of the profession.     

Modular construction of the protoderm and peripheral root cap in the “open” root apical meristem ofTrifolium repens cv. Ladino

Summary Roots with open apical organization are defined by not having specific tiers of initial cells in the root apical meristem; those with closed apical organization have specific initial tiers to which all cell files can be traced. An example of the clear organization of closed roots is the development protocol of the root cap and protoderm. The key event in differentiating these tissues is the T-division, a periclinal division of the root cap/protoderm (RCP) initial that establishes a module. Each module comprises two packets, the protoderm and peripheral root cap. Consecutive T-divisions of the same RCP initial produce up to five modules on average in a lineage of cells in white clover (Trifolium repens cv. Ladino), with all lineages around the circumference of the root dividing in waves to form one module prior to the next. On average, clover has approximately 32 axial protoderm and peripheral root cap cells in each module, and 32 RCP lineages. The occurrence of RCP T-divisions in white clover, a root with open apical organization, and the subsequent modular construction of the root cap and protoderm, provides a link between open and closed roots and suggests a common developmental feature that most roots of seed plants may share independent of their root meristem organization type. The open apical organization of the white clover root varies from roots with closed apical organization in that the RCP initials occur in staggered positions instead of connected to discrete tiers, and the peripheral root cap and columella daughter cells form additional layers of cells. White clover also forms root hairs on all protoderm cells irrespective of their position relative to the underlying cortical cells.Abbreviations RAM root apical meristem - RCP root cap protoderm - prc peripheral root cap     

Electron microscopical investigations of the intercellular contacts during the early cleavage stages ofLymnaea stagnalis (Mollusca,Gastropoda)

Summary In early cleavage stages ofLymnaea stagnalis, three kinds of intercellular junctions could be distinguished up to the sixth cleavage: intermediate, septate and gap junctions. The first two form junctional belts located on the cell border at the periphery of the embryo. For the purpose of our study we were most interested in gap junctions as they are alleged to be structures that allow cell-to-cell communication. Gap junctions first appear at the four cell stage. Up to the sixth cleavage no difference in the distribution pattern could be found between and within each of the four quadrants of the embryo. Some of the cell tiers along the animal-vegetal axis lack gap junctions either between the blastomeres within the tier or between the blastomeres from adjacent tiers. All gap junctions observed in freeze fracture replicas show plaques with an irregular IMP pattern. The average IMP diameter measures 12 nm (SD±2 nm). In stages fixed after the fifth cleavage, gap junctions are found between micromeres at the animal pole and the central 3D macromere. This is in agreement with the presumed interaction between these cells at this stage. The possibility of a transition of non-functional into functional gap junctions after the fifth cleavage is discussed.     

Weighting health states and strong evaluation

The problem of public consultation over the allocation of health care resources is addressed by considering the role that quality of life measures, such as QALYs and the Nottingham Health Profile, could play. Such measures are typically grounded in social surveys, and as such may reflect public preferences for health care priorities. Using Charles Taylor's concepts of "weak" and "strong" evaluation, it is suggested that current quality of life measures are inadequate, insofar as they typically presuppose that survey respondents are mere "weak evaluators", who express only inarticulate preferences. Respondents may, conversely, be understood as strong evaluators, with deeper visions of human nature and the good life informing their health preferences. Space is then created for such respondents to be asked to defend their preferences, and so be encouraged to reflect critically and publicly on the beliefs and prejudices that ground their view of health care priorities.     

A new method of biophysical allocation in LCA of livestock co-products: modeling metabolic energy requirements of body-tissue growth

Purpose

In agricultural life cycle assessment (LCA), the allocation method chosen to divide impacts among co-products is an important issue, since it may change conclusions about a product’s impacts. We developed a biophysical allocation method to assign upstream environmental burdens and the use of raw materials at farm gate to the livestock co-products at the slaughterhouse based on their metabolic energy requirements.

Methods

Biophysical allocation is designed to build a relationship between co-products of a meat-production system and their associated net metabolic energy requirements. A metabolic growth model (Gompertz function) was combined with an energy calculation model to estimate metabolic energy requirements for the growth of an animal from birth to slaughter age. Allocation factors were calculated based on the energy required to maintain and produce body tissues (excluding waste), as a function of their chemical (protein and lipid) and physiological properties. This method was applied for an average beef cow and then compared to other allocation methods (e.g., mass, dry matter, protein, and economic).

Results and discussion

At slaughter age, carcass tissues required the most energy (44 %) due to their high quantity of protein; the gastrointestinal tract and liver required about 28 and 5 %, respectively, of total metabolic energy requirements due to their roles in body metabolism. Biophysical allocation considers the energy cost of building and maintaining the tissues, regardless of their final uses. It reflects physical relationships among co-products as well as other allocation methods do. It also reveals the cause-effect relationship between tissues according to the energy required to maintain physiological functions. Once the growing time until slaughter is set, biophysical allocation factors are not influenced over time, unlike those of economic allocation, which is highly influenced by price variability.

Conclusions

This study provides a generic and robust biophysical allocation method for estimating environmental burdens of co-products, in accordance with ISO allocation rules. The method can be considered an original contribution to international debates on allocation methods applied to livestock products in LCA. In this paper, it is applied to cattle-related product, but it is generic and the principles can be adapted to any kind of livestock species. It should be considered and discussed by stakeholders in livestock production industries.