Tackling inequalities in health: the Australian experience.

Federal and state governments in Australia have embarked on a series of national initiatives which show a firm commitment to tackling social inequalities in health. The development of national goals and targets for health, for example, covers social and environmental conditions and sets differential targets for specific social groups with very poor health status. In a complementary initiative, a wide ranging analysis of the health care system--the National Health Strategy--has as one of its main objectives to improve the equitable impact of the health system. Where problems of access to and quality of services have been exposed, policies have been devised to deal with them. The exceptionally poor health of the Aboriginal community has elicited cross party support for action. Resources have been allocated to implement the National Aboriginal Health Strategy: to improve living and working conditions, education, and employment opportunities. Britain can glean much from the Australian experience.     

Community Demand for Doctors in the next 10 Years

The demand for doctors has increased despite improved community health, because the prevalence of chronic disease has increased, and because affluence, better education, and the growth of specialization have all stimulated demand.Most authorities have recommended an increase in the supply of doctors to meet the increasing demand. Nevertheless, a supply which preserves the present ratio of doctors to population might be adequate if medical productivity were raised. Moreover, an increase of the supply stimulates further demand; perhaps demand would fall if the supply were reduced, and community health might not deteriorate as a result of this.Other social institutions besides medicine have a claim on the available pool of talent from which doctors are recruited. It is possible that medicine already receives its fair share.     

Designing and scaling up integrated youth mental health care

Mental ill‐health represents the main threat to the health, survival and future potential of young people around the world. There are indications that this is a rising tide of vulnerability and need for care, a trend that has been augmented by the COVID‐19 pandemic. It represents a global public health crisis, which not only demands a deep and sophisticated understanding of possible targets for prevention, but also urgent reform and investment in the provision of developmentally appropriate clinical care. Despite having the greatest level of need, and potential to benefit, adolescents and emerging adults have the worst access to timely and quality mental health care. How is this global crisis to be addressed? Since the start of the century, a range of co‐designed youth mental health strategies and innovations have emerged. These range from digital platforms, through to new models of primary care to new services for potentially severe mental illness, which must be locally adapted according to the availability of resources, workforce, cultural factors and health financing patterns. The fulcrum of this progress is the advent of broad‐spectrum, integrated primary youth mental health care services. They represent a blueprint and beach‐head for an overdue global system reform. While resources will vary across settings, the mental health needs of young people are largely universal, and underpin a set of fundamental principles and design features. These include establishing an accessible, “soft entry” youth primary care platform with digital support, where young people are valued and essential partners in the design, operation, management and evaluation of the service. Global progress achieved to date in implementing integrated youth mental health care has highlighted that these services are being accessed by young people with genuine and substantial mental health needs, that they are benefiting from them, and that both these young people and their families are highly satisfied with the services they receive. However, we are still at base camp and these primary care platforms need to be scaled up across the globe, complemented by prevention, digital platforms and, crucially, more specialized care for complex and persistent conditions, aligned to this transitional age range (from approximately 12 to 25 years). The rising tide of mental ill‐health in young people globally demands that this focus be elevated to a top priority in global health.     

我国暴力伤医事件成因的政策分析及应对

暴力伤医事件是我国医患信任解体的具体表现,并有逐年上升的趋势,它已严重威胁到医疗正常秩序。清晰的阐释其复杂的成因并提出政策应对建议,对减少暴力伤医以及构建和谐医患关系具有重要意义。本文旨在剖析伤医事件的成因的政策根源,并提出相应的政策应对策略及意见,进而为构建和谐的医患关系提供理论参考。     

Childproof caps open Pandora's box

This fall Ontario braced for possible strikes by public servants and teachers. A year earlier, the province''s physicians were preparing their own job action. Walkouts by physicians, which have not been uncommon since the introduction of medicare, create two camps. In one are physicians who say legal job actions are ethical and often improve health care for patients. In the other are some doctors and ethicists who question whether doctors have an ethical right to withdraw services, even if it is legal to do so. Nicole Baer interviewed members of both camps.     

Canadian Medicare: prognosis guarded.

Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.     

The effects of maternal-child health service utilization on subsequent contraceptive use in Morocco.

There are a number of reasons for anticipating that contact by women in developing country settings with modern maternal-child health (MCH) services will lead to increased use of family planning services. Indeed, the expectation of such a relationship underlies the integrated service delivery strategy that has been adopted on a more or less global basis. However, the available empirical evidence in support of this proposition is inconclusive. This study re-examines this issue in Morocco. Household survey data and data on the supply environment for health and family planning services gathered in 1992 are analysed in the study. A full-information maximum likelihood estimator is used to control for the possible endogeneity of health care and contraceptive choices. The findings indicate a substantial and apparently causal relationship between the intensity of MCH service use and subsequent contraceptive use. Policy simulations indicate that sizeable increases in contraceptive prevalence might be realized by increasing the coverage and intensity of use of MCH services.     

Health in China. The healthcare market.

It is now about 15 years since the introduction of the market into health care in China. This produced fundamental changes in the way that health care is financed and resulted in the disappearance of universal free basic health care. Responsibility for provision of health services has been devolved to the provincial and county governments, and healthcare providers have been given considerable financial independence. A fee for service system has been introduced, and several different payment mechanisms are now in operation. The new financing and pricing structures are responsible for greater inequity of access to services and more inefficient use of resources. These problems are widely acknowledged, and a range of solutions is being developed and tested. Since the introduction of the reforms the measurable health status of the population has not declined, probably as a result of overall improved socioeconomic conditions and a continued emphasis on prevention.     

Behavioral health care integration in obstetrics and gynecology

Depression, anxiety, and somatoform disorders are 2 to 3 times more prevalent in women than in men. Since the advent of managed care and other pressures on the healthcare delivery system in the United States, there has been a notable diminishment of services and service funding for treatment of mental health conditions, whether they are temporary, transitional, or chronic. As a result of this trend, we have seen an increase in the number of patients seeking help for emotional and mental health concerns from their family doctors or, in the case of women, from their obstetrician-gynecologists. We have also found that emotional and mental health problems are often converted into physical symptomatology that carries fewer stigmas and is often viewed as easier to treat. Many women use their obstetrician-gynecologists for primary care, particularly during their reproductive years. Provision of behavioral healthcare is critical to health maintenance for many of these women. Barriers to the integration of behavioral healthcare into obstetrics and gynecology practice need to be understood and systemically addressed.     

Lay testing cadres and point-of-care diagnostic tests for HIV and other diseases: An essential combination in health service delivery

Zibusiso Ndlovu and Tom Ellman discuss the potential value of task sharing in provision of testing for HIV and other infectious diseases.

Summary points

• Lack of access to testing plays a major role in the underdiagnosis of infectious and noncommunicable diseases, leading to higher morbidity and mortality.
• Point-of-care (POC) tests can offer rapid results, allowing for timely initiation of therapy. However, mere availability of POC tests in health facilities does not ensure utilization. Conducting POC tests has been shown to be a burden on highly trained frontline healthcare workers (HCWs; clinicians and nurses), who often have a broader scope of responsibilities and are critically scarce in many settings.
• The continual emergence of easy-to-use POC tests has not been accompanied by investment in a cadre of health workers to support their delivery, especially at decentralized health facilities where patients initially seek healthcare support.
• Historically, implementation of task shifting for POC tests has proven difficult due to lack of integration into national human resource structures and fiscal plans and lack of explicit national policies promoting task shifting, together with resistance from laboratory professionals.
• We propose that the scope of work for existing lay health worker (LHW) cadres could be broadened/remodeled to include POC tests for HIV services including for advanced HIV disease and other priority diseases, especially in primary healthcare or lower level facilities without laboratories. Policy makers and national program managers could ensure that this is part of broader national health workforce policies.
• Concerns of professional and/or regulatory bodies must be addressed, and these bodies (medical and laboratory councils) can guide national policy on which POC tests can be task shifted to less laboratory-trained cadres, and they could also lead in the development of a framework of education and supervision to ensure sustainability and maintenance of professional standards.
• Lay testing initiatives can scale up access to the multitude of available essential POC tests, for maximal impact of disease testing, closer to where people live. This can improve global health and accelerate progress toward universal health coverage.

     

Maternal and child health in China.

China has made great progress in improving the health of women and children over the past two generations. The success has been attributed to improved living standards, public health measures, and good access to health services. Although overall infant and maternal mortality rates are relatively low there are large differences in patterns of mortality between urban and rural areas. The Chinese have developed a hierarchical network of maternal and child health services, with each level taking a supervisory and teaching role for the level below it. Maternal and child health in China came to international attention in 1995 with the promulgation of the maternal and child health law. In China this was seen as a means of prioritising resources and improving the quality of services, but in the West it was widely described as a law on eugenics.     

Public health 2020.

The aim of public health is to improve the health of people in communities and in populations (protection from environmental hazards and provision for health needs). The challenge for public health doctors is to re-establish public health leadership of communities, address social and environmental causes of ill health, and link with primary care (a) to improve the health of neighbourhoods and (b) to combine perspectives in commissioning services. Current threats derive from organisational philosophies. For example, focusing on market development does not allow for population based functions and so neglects the main influences on health. The way forward is a network model of organisation in which small teams collaborate with each other to the common good. For example, successful commissioning authorities would have the public health leadership of the director of public health and the support of the chief executive, treasurer, and representatives of primary care, including a medical adviser from the family health services authority.     

Can contracts drive clinical care?

The instrument through which a commissioner purchases health services from a provider is, as in other walks of life, a contract, so considerable importance has been attached by the NHS Executive to the contracting mechanism. A contract should in theory influence the quality of the service provided, but they are in many cases an inappropriate vehicle for driving clinical care. Much clinical activity is related to the management of chronic diseases and the effects of aging. The implicit contract here is based not on process and outcome measures but on mutual trust between doctors and patients that the doctors will provide the best care they can within budgetary constraints.     

Counties selecting public health priorities--a "bottom-up" approach (Croatian experience)

The subject of this paper is how to incorporate a multi-disciplinary and inter-sectored approach into development of public health policy and plans at the local (county) level in Croatia by educational program. Method used was the public health capacity building program "Health--Plan for it", which was developed with the aim to assist the counties to overcome recognized weaknesses and introduce more effective and efficient local public health practices. Two main instruments were used: Local Public Health Practice Performance Measures Instrument, and Basic Priority Rating System. This program has helped counties to asses population health needs in a participatory manner, to plan for health and, ultimately, assure provision of the right kind and quality of services (better tailored to population health needs). This program's benefits are going beyond and above the county level. It provides support for the Healthy Cities project locally, and facilitates changes in national policymaking body's mindset that a "one-size-fits-all" approach is sufficient.     

Creating a new drug service in Edinburgh.

After one year Edinburgh''s Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.     

Out of hours service: the Danish solution examined.

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing complaints from rural doctors about their heavy workload and disproportionately low remuneration in comparison with urban doctors. As a result, the out of hours service was reformed at the start of 1992: locally negotiated rota systems were replaced with county based services. Each county now has a coordination centre, where all patients'' calls are received by a team of doctors. The doctors may give a telephone consultation, advise the patient to attend one of the emergency clinics strategically placed about the county, or arrange for a home visit. Doctors on home visiting duty are located at bases throughout the county and keep in touch with the coordination centre with mobile telephones. Graded fees mean that doctors are encouraged to give telephone consultations rather than arrange for clinic consultations or home visits. The reforms have reduced doctors'' out of hours workload and the number of home visits made and have proved acceptable to patients, doctors, and administrators.     

Analysis of the tradeoffs between provisioning and regulating services from the perspective of varied share of net primary production in an alpine grassland ecosystem

Because ecosystems are complex, tradeoffs exist among supplies of multiple ecosystem services, especially between the provisioning and regulating services. In ecosystem processes, net primary production (NPP) is connected with many other processes such as respiration and evapotranspiration. As one key supporting service, NPP is also related to other provisioning and regulating services. This study introduces an analysis framework of ecosystem services tradeoffs from the perspective of varied share of NPP, in the alpine grassland ecosystem of Damxung County on the Tibetan plateau, China. Total NPP was divided into the share of NPP spent on supplying provisioning services and the share used in supporting regulating services. Tradeoffs between provisioning and regulating services were analyzed by quantifying the change of meat provisioning service and the remaining share of NPP used in other ways; the corresponding change in the share of NPP used to support regulating services was also analyzed and compared with other changes in regulating services, such as carbon sequestration and water conservation services. The results show, from 2000 to 2010, the meat provisioning service increased by 199%, but this was at a cost of additional livestock feeding, which used more NPP of the alpine grassland ecosystem. As a result, by 2010 the remaining NPP used for supporting regulating services shrank to 77% of the 2000 level, which was accompanied by a decrease in carbon sequestration and water conservation services by 90% and 67%, respectively. The analysis of tradeoffs from the perspective of variations in the share of NPP used for various services will contribute to the study of mechanisms involved in providing ecosystem services, interactions between the provisioning of various services, and will also help land managers improve the management of ecosystems.     

Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea,Uganda, and Sierra Leone

BackgroundLittle is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs.ConclusionsNational health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.     

Out-of-pocket health care expenditures due to excess of body weight in Portugal

The prevalence for excessive weight has also been increasing dramatically in Portugal over the last decades. The consequences for families as well as for the publicly funded Portuguese health care system are a matter of policy interest. This paper uses an econometric model to compute the fraction of the national out-of-pocket health care expenditures attributable to overweight and obesity among Portuguese adults. Given that public health care system pays for a substantial share of the national health care expenditures, the estimated the out-of-pocket expenditures is only a share of the total expenditures. Per-capita expenditures and the burden that obesity and overweight impose on families are also estimated. Two waves of the Portuguese National Health Survey (NHS), namely; 1995/1996 and 1998/1999 are considered. The results suggest that out-of-pocket expenditures due to excess weight have increased sharply during these 3 years. The two-part model estimates suggest that the obese and overweight are more likely to incur out-of-pocket health care expenditures but, in the restricted sample of those that incur expenditures, there is weak or no evidence that the obese or overweight spend, on average, more than those of normal weight. Overall, it is estimated that in 1995/1996, more than 1.8% out-of-pocket health care expenditures were attributable to obesity and 2% to overweight (although not statistically significant). The estimated percentages are over 2.9% for obesity and 4% for overweight in 1998/1999. Combined, the estimated attributable percentage of national out-of-pocket expenditures due to excess weight was 3.8% in 1995/1996 and 6.9% in 1998/1999. Per-capita expenditures due to obesity or overweight are small, on average, in absolute terms, but they can be a significant cost for low income families. With respect to public policy concerns, the results suggest that measures which only slightly increase the out-of-pocket health care expenditures of being obese (overweight) are likely to be inefficient.     

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

Background

There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.

Methods and Findings

We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.

Conclusion

African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors'' Summary