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PubMed2004

Global perspectives on vaccine financing.

Despite the great promise of immunization and recent progress in immunizing children throughout the developing world, a global crisis in vaccine R&D, supply and delivery is faced. This article reviews how the global US6 billion dollars vaccine market is structured and its attractiveness to vaccine suppliers, the international two-tiered pricing system in which high-income countries generate about 82% of vaccine revenues but represent only 12% of the doses, the impact of schedule divergence as high-income and developing countries introduce different vaccines, the role of the US government, and possible approaches to ameliorate the crisis.

Developed Countries↗

PubMed1988

Republic Act No. 6657, 10 June 1988.

This Act institutes the Comprehensive Agrarian Reform Program (CARP). CARP takes as its declared aim "the establishment of owner cultivatorship of economic-size farms as the basis of Philippine agriculture" (Section 2). It prohibits the retention by landowners of more than five hectares of land and, for each child of the landowner over 15 years old, an additional three hectares, providing he or she is personally cultivating that land (Section 6). That limit of three hectares is also the upper limit for the redistribution of land to "qualified beneficiaries." These may be agricultural lessees and share tenants, regular, seasonal, or other farm workers, actual tillers or occupants of public lands, or some others directly working on the land (Section 22). Where splitting up of the land is economically inappropriate, then it may be taken over by collectives or cooperatives of these categories of agricultural workers (Sections 25 and 29). The land reforms envisaged under CARP are scheduled to take place in three phases over a 10-year period. Land in the public domain held or leased by multinational corporations is scheduled for expropriation within three years of the passing of the Act (Section 8); land otherwise controlled to be redistributed during the first phase is generally scheduled for redistribution in order of the size of the landholdings: that is, the larger the holding, the earlier it is scheduled for redistribution. Land acquisition is to be carried out by means of the Department of Agrarian Reform (DAR) and the Land Bank of the Philippines (LBP). The level of compensation payable to the expropriated landowner is to be determined by the DAR, the LBP, and the landowner, according to the cost of acquisition and development of the land, current market values, the income it generates in the light of the sworn valuation of the owner, and any tax returns pertaining to it. If the landowner disagrees with the level of compensation offered, there is a right of appeal to the courts. Payment of compensation, carried out through the medium of the LBP, is to be partly in cash and partly in government bonds, or in credits for taxes or other government funded services such as education and hospitalization. For land in excess of 50 hectares, the proportion payable in cash is 25% and for land below 24 hectares in area, 35%. These amounts may be increased by 5% in cases where the landowner voluntarily puts the land forward for transfer under the Program.

Agriculture↗

PubMed2005

Computer model for municipal solid waste treatment in developing countries.

Many integrated solid waste management (ISWM) models are available but are of little use to developing countries such as India since they do not take into account typical developing countries municipal solid waste characteristics such as high organic content, poor performance of formal sector control and support, high activity of scavengers and waste pickers, etc. The goal of this study is to create a computer program to determine the least cost treatment and disposal system for a given solid waste management problem. To demonstrate its applicability, the model was applied to the Indian city Amritsar. A typical Indian city like Amritsar generates about 500 ton of MSW/d with 45% moisture content, 30% volatile matter, and calorific value of 1500 kcal/kg. The computer model was run for various technologies. Results showthatfor Amritsar city incineration an expenditure of U.S. dollars (USD) 6.62 is incurred, whereas landfilling, composting, and biomethanation digester give an income of USD 0.13, USD 0.20, and USD 0.23 per ton of MSW, respectively. This empirical exercise not only reveals the model's strengths such as highlighting important interdependencies in the waste management sector but also its requirement for quality data.

Bacteria, Anaerobic↗

PubMedDate not supplied

Reaching and educating the global tobacco control community: innovative approaches to tobacco control training.

To slow and end the growing global burden of tobacco-related death and disease, schools of public health need to provide tobacco control education and training for public health professionals generally, and for the next generation of tobacco control professionals in low- and middle-income countries specifically. As the tobacco epidemic continues to grow, there is an increasing need for training to develop the research and intervention skills required to stem the epidemic and reduce the inevitable burden of disease and death. A wide range of educational approaches has been developed to increase tobacco control educational capacity in high-, middle-, and low-income countries, including traditional on-site classes, on-line courses, open source courseware, summer school programs, and training workshops. This article provides a perspective on the education and training needs of tobacco control researchers around the world and reviews the strengths and weaknesses of education and training approaches currently being used in tobacco control by schools of public health. In each case, we draw on the experience of the Johns Hopkins Bloomberg School of Public Health in educating national and international audiences in tobacco control.

Baltimore↗

PubMed1991

Making sense of inequalities: a response to Peter Townsend.

This article addresses the continuing controversy generated by the Black Report on Inequalities in Health, published in Britain in 1980, in response to the defense offered by Professor Peter Townsend. The author argues that Townsend's riposte to the critics of the Black Report is flawed in at least two respects. First, Townsend fails to acknowledge that the Black Report was as much an exercise in policy advocacy as in scholarly analysis, making rather large assumptions about the links in the reasoning leading to its recommendations for a massive program of income redistribution. Second, Townsend's defense of Black's use of social class as its main tool for analyzing health inequalities dismisses too easily much of the evidence; for example, the effects of social mobility and the historical dimension. Moreover, by concentrating on social class, a heterogeneous category, analysis may ignore what is most relevant for policy-making: i.e., specific factors associated with specific forms of deprivation, located within social classes or particular geographical communities. It would therefore be more constructive if scholars were to accept and research this complexity, rather than defending the Black Report as though it were a definitive (not to say sacred) text.

Adolescent↗

PubMed2005

The macro determinants of health expenditure in the United States and Canada: assessing the impact of income, age distribution and time.

This paper examines the determinants of real per capita health expenditures in order to assess the impact of age distribution, income and time using American state-level data for the period 1980-1998 and Canadian province-level data for the period 1975-2000. Ageing population distributions and income explain a relatively small portion of health expenditures when the impact of time effects, which is a partial proxy for technological change, is controlled for. However, the impact of age is of more concern given that cost increases are concentrated in the last few years of life and there may be cohort effects as the "Baby-Boom" generation ages. There is an urgent need to better understand the exact mechanisms driving health expenditure increases given that time accounts for approximately two-thirds of health expenditure increases and that its effect is non-linear.

Age Distribution↗

PubMed1990

An incentive program to increase revenue in a public hospital.

Using financial reward systems to enhance revenue generation or promote cost savings has been more difficult in public than in private hospitals. The program at the Los Angeles County-University of Southern California Medical Center has demonstrated, however, that it can be done.

Cost Control↗

PubMed1995

Follow the money: funding streams and public health nursing.

The increasing reliance of health departments on income generated by billing for individual clinical services impacts the role and outlook of public health nurses. This commentary discusses some of the reasons for the emergency of that finance trend and the current shifts in financing personal care, with observations on the challenges facing nurses in public health agencies today.

Community Health Services↗

PubMed1995

The use of a break-even analysis: financial analysis of a fast-track program.

OBJECTIVE: To calculate the financial break-even point and illustrate how changes in third-party reimbursement and eligibility could affect a program's fiscal standing. METHODS: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast-track program during June 1993. The fast-track program is located within the confines of the emergency medicine and trauma center at a 1,050-bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break-even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect. RESULTS: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs. CONCLUSIONS: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third-party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break-even volumes.

Cost-Benefit Analysis↗

PubMed1999

Suprachiasmatic nucleus: the brain's circadian clock.

The tiny suprachiasmatic nucleus (SCN) of the hypothalamus plays a central role in the daily programming of organismic functions by regulating day-to-day oscillations of the internal milieu and synchronizing them to the changing cycles of day and night and of body state. This biological clock drives the daily expression of vital homeostatic functions as diverse as feeding, drinking, body temperature, and neurohormone secretion. It adaptively organizes these body functions into near-24-hour oscillations termed circadian rhythms. The SCN imposes temporal order 1) through generating output signals that relay time-of-day information, and 2) through gating its own sensitivity to incoming signals that adjust clock timing. Each of these properties, derived from the timebase of the SCN's endogenous near-24-hour pacemaker, persists when the SCN is maintained in a hypothalamic brain slice in vitro. Single-unit recording experiments demonstrate a spontaneous peak in the electrical activity of the ensemble of SCN neurons near midday. By utilizing this time of peak as a "pulse" of the clock, we have characterized a series of time domains, or windows of sensitivity, in which the SCN restricts its own sensitivity to stimuli that are capable of adjusting clock phase. Pituitary adenylyl cyclase-activating peptide (PACAP) and cAMP comprise agents that reset clock phase during the day time domain; both PACAP and membrane-permeable cAMP analogs cause phase advances only when applied during the day. In direct contrast to PACAP and cAMP, acetylcholine and cGMP analogs phase advance the clock only when applied during the night. Sensitivity to light and glutamate arises concomitant with sensitivity to acetylcholine and cGMP. Light and glutamate cause phase delays in the early night, by acting through elevation of intracellular Ca2+, mediated by activation of a neuronal ryanodine receptor. In late night, light and glutamate utilize a cGMP-mediated mechanism to induce phase advances. Finally, crepuscular domains, or dusk and dawn, are characterized by sensitivity to phase resetting by the pineal hormone, melatonin, acting through protein kinase C. Our findings indicate that the gates to both daytime and nighttime phase resetting lie beyond the level of membrane receptors; they point to critical gating within the cell, downstream from second messengers. The changing patterns of sensitivities in vitro demonstrate that the circadian clock controls multiple molecular gates at the intracellular level, to assure that they are selectively opened in a permissive fashion only at specific points in the circadian cycle. Discerning the molecular mechanisms that generate these changes is fundamental to understanding the integrative and regulatory role of the SCN in hypothalamic control of organismic rhythms.

Animals↗

PubMed2000

National and state policies influencing the care of children affected by AIDS.

The portrait of HIV-affected children and youth that emerges from this policy overview is still one of children obscured from view by the shadow of their parents' and siblings' illness and policies that only address the needs of HIV-infected individuals. In addition, the secrecy and stigma that still surround HIV and AIDS make it difficult for HIV-affected children and youth to benefit as fully as they might from policies and programs that provide more generic types of care and assistance. Our failure as a nation to better illuminate the plight of HIV-affected children and youth can only leave us with a generation of children who are at greater risk of psychiatric illness, involvement with the criminal justice system, substance abuse, and contracting HIV. To avoid these consequences, both public and private sectors must place the spotlight on the development of new policies and programs designed to specifically meet their needs. Because the solutions defy traditional disciplinary and administrative boundaries, we also need to become more skilled at interagency planning and collaboration. No one system alone can be responsive to the many social, mental health, legal, and support needs of these children and their caretakers. More specifically, recommendations for improved systems of care to HIV-affected children, youth, and their families are as follows: To promote and fund cross-disciplinary initiatives among agencies that administer child welfare services, income supports, AIDS care, and children's mental health services at the national, state, and local levels to specifically meet the mental health, psychosocial, and permanency planning needs of HIV-affected children and youth. To provide training opportunities for Ryan White Title I, II, and III case managers on assessing the needs of HIV-affected children and youth, developmental theories and concepts, principles of family-centered care, and child welfare issues. To increase funding of the Ryan White CARE Act to permit a more family-centered approach to care across Titles. To establish clearer guidelines for establishing a proportional basis for funding services to infants, children, and women under the Ryan White CARE Act. To support legislative, educational, and advocacy efforts to make managed care and welfare reform more responsive to the needs of HIV-affected children, youth, and their families. To encourage states to provide additional funding for mental health services specifically targeted to HIV-affected children and youth that are sufficiently flexible and of a long enough duration to adequately meet their needs. Surely, as we move into a new millennium with the capacity to map the human genome and clearly view distant galaxies, we should be able to marshal the will and resources necessary to formulate a sufficiently focused effort to respond compassionately and effectively to the needs of a generation of AIDS-affected children and youth.

Acquired Immunodeficiency Syndrome↗

PubMed1999

1998-1999 SAEM emergency medicine faculty salary and benefits survey.

OBJECTIVES: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 1998 residency review committee (RRC)-EM-accredited programs using the SAEM fourth-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. METHODS: Blinded program and individual faculty data were entered into a customized version of FileMaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria, including department staffing levels, ED volumes, ED length of stay, department income sources, salary incentive components, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies. RESULTS: Seventy-three of 120 (61%) accredited programs responded, yielding usable data for 70 programs and 965 full-time faculty among the four AAMC regions. Mean salaries were reported as follows: all faculty, $167,478; first-year faculty, $140,616; programs reporting data to the AAMC, $161,794; programs not reporting data to the AAMC, $165,724. Mean salaries as reported by AAMC region: northeast, $167,876; south, $160,586; midwest, $190,957; west, $148,977. CONCLUSIONS: Reported salaries for full-time EM residency faculty continue to rise. Significant regional differences in salaries have been present in all four SAEM surveys. Nonclinical hours are compensated at approximately one-half the rate paid for clinical hours. The demographic data indicate that EM residency faculty are working at the upper extremes of numbers of patient encounters per physician, patient acuity levels, and department lengths of stay.

Certification↗

PubMed2003

[Poverty, inequality, and equity in health: considerations based on a transversal gender perspective].

This article discusses the modernization of gender inequalities which has occurred in Brazil in the last 20 years under the hegemony of neo-liberal macro-economic policies. A concept of gender as transversal is applied to questions of reproductive health (contraception and abortion, prenatal care and birthing, adolescent pregnancy, maternal and reproductive mortality, STIs/AIDS, and violence, among others), permitting analysis by both gender and social class. The history of the PAISM (Program for Integral Health Care for Women), on the other hand, reveals the complex articulation of this national public health program which, although strongly influenced by the Brazilian women's movement, has been infiltrated by heterogeneous interests in the international context. PAISM serves as an example of the appropriation of proposals and principles that were generated by this social movement, but re-articulated to gloss over the process of deepening gender and class inequality.

Adolescent↗

PubMed2004

Mailings timed to patients' appointments: a controlled trial of fecal occult blood test cards.

BACKGROUND: Fecal occult blood testing (FOBT) programs cost-effectively reduce colon cancer mortality. To improve the rate of colon cancer screening with FOBT, we tested the effect of mailing FOBT cards timed to appointments on the rates of completion of FOBT. DESIGN: Controlled trial. SETTING/PARTICIPANTS: A total of 119 patients with primary care appointments scheduled in May or June 2000 for an urban, public hospital clinic that serves predominantly low-income, African Americans with chronic diseases. The patients in the study were selected by linking a quality improvement registry, the appointment system database, and an FOBT database to generate a list of clinic patients who had not completed an FOBT in the preceding year. INTERVENTION: Subjects were assigned to either a system of mailing FOBT cards and reminders 2 weeks prior to a scheduled appointment or usual care. MAIN OUTCOME MEASURES: The primary outcomes were the rate of screening at the index appointment and during the year beginning with the date of the index appointment. RESULTS: The rate of return of the FOBT cards during the year beginning with the index appointment was 40.7% for the intervention group compared to 5% for the usual care group (odds ratio [OR]=13.0, p <0.001). The difference was accounted for largely by increases in screening at the index appointment (35.6% compared to 3.3%, OR=16.0, p <0.001). CONCLUSIONS: Using computer databases to generate a list of patients due for FOBT and then mailing FOBT cards timed to a scheduled appointment significantly increased the rate of colon cancer screening. This may be an efficient approach to increasing colon cancer screening with FOBT.

Appointments and Schedules↗

PubMed2006

Caring for the new uninsured: Hospital charity care for older people without coverage.

Despite near-universal coverage through Medicare, a number of elderly residents in the United States do not have health insurance coverage. To the author's knowledge, this study is the first to document trends in the use of hospital charity care by uninsured older people. Data from the New Jersey Charity Care Program, which subsidizes hospitals for services provided to low-income uninsured people, were used to analyze trends in charity care utilization by older people from 1999 to 2004. Charity care charges are standardized to uniform Medicaid reimbursement rates and inflation adjusted using the Medical Care Consumer Price Index. From 1999 to 2004, use of charity care by older people grew much faster than it did for younger patients. As a result, older people now account for a greater share of hospital charity care in New Jersey than children. Elderly users of charity care generated higher costs per patient than their younger counterparts. Cost differences were especially salient at the upper end of the distribution, where high-cost elderly patients used significantly more resources than high-cost patients in other age groups. These results highlight an emerging source of strain on the healthcare safety net and point to a growing population of uninsured residents who have costly and complex medical needs. Similar experiences are likely to be found in other states, especially those that have growing populations of elderly immigrants who are likely to lack health insurance.

Adult↗

PubMed1998

Provide, provide: the economics of aging.

Most older persons face two potentially serious economic problems: (a) declining earning power and (b) declining health that can be partly offset by increased utilization of health care. The decline in earning power is largely attributable to physiological changes and to obsolescence of skills and knowledge. These adverse effects are exacerbated by public and private policies that reduce the incentives of older persons to continue work and increase the cost to employers of employing older workers. The problems of earnings replacement and health care payment are usually discussed separately, but there are several reasons why they should be considered together. First, there are often tradeoffs between the two. Money is money, and for most people there is never enough to go around. This is self-evident where private funds are concerned. Low-income elderly, for instance, frequently must choose between expensive prescription drugs and an adequate diet. For middle-income elderly, the choice may be between saving on medigap insurance or forgoing an airplane trip to a grandchild's graduation. Difficult choices are also inherent in the allocation of public funds. The same tax receipts that could be used to maintain or increase retirement benefits could be used to fund additional care, and vice versa. In discussing these tradeoffs, some analysts assert that people will gladly give up other goods and services for medical care that cures illness, relieves pain, or restores function. Others believe that some people would forgo some health insurance in order to maintain access to other goods and services. A second reason for looking at the two problems together is that they pose similar questions for public policy. How much should each generation provide for its own needs in old age, and how much should be provided by the generations that follow? How much provision should be voluntary, how much compulsory? How much intra-generational redistribution is appropriate after age 65? How well can private markets serve the elderly's desire for annuities and health insurance, and when are public programs more efficient? Finally, the problem of health care payment is approaching that of earning replacement in economic importance and, by 2020, will far exceed it. Declining health after age 65 results in substantial increase in use of prescription drugs, hospital admissions, repair or replacement of parts of the body, rehabilitation and physical therapy, and assistance with activities of daily living. New technologies offer great promise for offsetting the health problems of aging, but often at considerable expense. Overall, per capita expenditures for health care after age 65 are between three and four times as great as for those under 65. This presentation will focus primarily on the (thus far) inexorable increase in consumption of health care by older Americans. If this increase continues and if the government's share of the total remains unchanged, the tax burden on younger cohorts could become intolerable. Concomitantly, if the private share remains unchanged, the ability of the elderly to obtain other goods and services would be sharply diminished. Although the emphasis of the session will be on aggregate and average results, levels and trends in income inequality among the elderly will also be examined and compared with inequality at younger ages. The session will conclude with a discussion of changes that might avert the economic and social crises foreshadowed in the data.

Aged↗

PubMed2001

[Morphological evaluation of posterior capsule opacification in diffractive multifocal intraocular lenses].

BACKGROUND: Diffractive multifocals belong to the first generation of multifocal intraocular lenses. Dure to their optical principle of diffraction multifocals separate the incoming light on two foci (41%) with 18% loss of scattered light. Therefore, reduced contrast sensitivity and glare have been frequently described with this lens. PATIENTS AND METHODS: We evaluated 42 eyes of 25 patients (age at surgery 63.8 +/- 8.8 years) 3 years after implantation of a Pharmacia 811E diffractive multifocal (MIOL). They were tested for functional results including contrast and glare (Mesoptometer II). In addition 22 eyes were evaluated for posterior capsule opacification (PCO) using digitalized retroilluminations photographs and the EPCP image analysis program. RESULTS: Average visual acuity was 0.77 +/- 0.20 (uncorrected distance), 0.93 +/- 0.21 (corrected distance), 0.94 +/- 0.13 uncorrected near) und 0.98 +/- 0.08 (best corrected near). PCO-values quantified by EPCO were 1.13 +/- 0.59 (Range 0.07 to 2.1). On average 18.1 +/- 14.9% of the optic area showed an opacification grade 1, 35.8 +/- 26.6% grade 2 and 7.7 +/- 17.1% grade 3. Contrast sensitivity showed no patient with contrast level 7 or better for monocular evaluation, but 30% for binocular testing. Only 4% met the criteria for night driving when tested for glare. Spearman correlation did not reveal any significant correlation between PCO-values and visual acuity, contrast sensitivity or glare (all p > 0.24, all r < 0.22). CONCLUSIONS: Patients with diffractive multifocal IOLs showed excellent results for near and distance visual acuity three years after implantation. However, contrast and glare results were poor, probably due to a rather high PCO-rate. Future developments of the lens type should include PCO-reducing factors, such as sharp edge optics and foldable materials.

Aged↗

PubMed2006

ADEA survey of clinic fees and revenue: 2003-04 academic year.

The American Dental Education Association's 2003-04 Survey of Clinic Fees and Revenue obtained data by which to report, by school, clinic revenue information per student. Fifty-one of the fifty-four dental schools that had third- and fourth-year students responded to the survey. The median revenue per third-year student was dollar 9,937. It was dollar 13,602 for fourth-year students. Clinic revenue was also obtained for programs of advanced dental education. General Practice Residency programs generated the highest revenue per student at dollar 66,474, followed by programs of Advanced Education in General Dentistry at dollar 63,860. Other areas of the survey provided information regarding clinic fees by type of program, levels of uncompensated care by type of program, clinic revenue by source of payment, and dental school fees as a percent of usual and customary private practice fees.

Data Collection↗