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Private-public mix: a prioritisation under RNTCP--an Indian perspective.

Success of the public directly observed treatment, short course (DOTS) programmes have been widely reported from various parts of the world and have been described from the Indian subcontinent as well. But, it is being increasingly realised that further DOTS successes can take place only by ensuring a private sector participation under the programme. While discussing behaviour-profile of patients, this review enumerates possible reasons for their averseness of a public health facility and preference for a private health. facility. Similarly, behaviour-profile of private health providers brings out the discrepancies in their clinical practices. Both types of profiles are supported with the studies from India and abroad. A comparison is drawn between available services of the public and private health facilities, with a focus on the need for prioritisation of a private-public mix (PPM) in the Revised National Tuberculosis Control Programme (RNTCP). Furthermore, the salient features of schemes recommended by the Directorate General of Health Services, New Delhi, for involvement of the private- practitioners, and the Non-Governmental Organisations are briefly outlined. The underlying obstacles for private sector participation in RNTCP and the projected solutions so as to effect a private-public mix in the Revised Programme are also dealt with. A description of few operating models, trying in the best possible manner to bring about a private sector participation in programme, is presented to make the readers aware of the efforts going on in that direction within the country. The private health sector, easily being a patient's first choice, needs to be integrally involved in RNTCP on a priority basis, feasibility of which, has been successfully documented in the operational trials conducted within the country so far.

Antitubercular Agents↗
PubMed1992

Audit of prioritisation for coronary revascularisation procedures: implications for rationing.

OBJECTIVE: to audit prioritisation of patients awaiting coronary revascularisation. DESIGN: the case records of 92 Christchurch patients referred for coronary artery bypass surgery (CABG) or percutaneous transluminal angioplasty (PTCA) from January to April 1990 were reviewed. The actual waiting time was compared with a nominally optimal waiting time, determined from an urgency rating score based primarily on severity of angina and coronary anatomy. RESULTS: of 56 patients referred for CABG, 47 had left main or multivessel disease including proximal stenosis of the left anterior descending artery. Fifty had Canadian class III or IV angina and 18 had impaired left ventricular function. At the time of review (January 1991), 16 had not yet had an operation. The mean waiting time was at least 163 (SD 116) days. Only nine (16%) had CABG within the maximum optimal time. Thirty-six patients had PTCA within eight months, mean waiting time 80 (53) days. These patients had less severe disease, but similar severity of angina. Nineteen (53%) had their procedure within the optimal period. CONCLUSION: waiting times for coronary revascularisation are excessive, even for high risk patients. Prospective monitoring of the waiting list using a standardised urgency rating score is likely to provide useful information on the dynamics of the waiting list for coronary revascularisation. Furthermore, the effects of further rationing of services can be analysed.

Aged↗
PubMed2005

Prioritisation of elective surgery in New Zealand: The Reliability Study.

AIMS: This paper describes the rationale and methodology of a study assessing the reliability of tools for clinical prioritisation (Clinical Priority Assessment Criteria [CPAC]) of patients for elective surgery in New Zealand. METHODS: Surgeons from three specialties (general, vascular, and orthopaedic surgery) completed a computerised evaluation rating clinical vignettes across a range of diagnoses using several priority tools. The study design is described and an outline of the individual tool development and definitions is given. RESULTS: Of the 124 surgeons that participated in this study, 48% (60) were general surgeons, 21% (26) were vascular surgeons and 31% (38) were orthopaedic surgeons. The response rates in the first phase of data collection were 67%, 79%, and 63% for general, vascular, and orthopaedic surgery respectively. Completion rates were high with 100%, 93%, and 98% of the same groupings of surgeons completing the first round evaluations. A further 77% to 89% of the participants from the first round also completed the re-test evaluation. CONCLUSION: This study indicates that assessment of the reliability of CPAC tools currently in use in New Zealand is feasible using a vignette-based approach. In the future, study designs that allow for some face-to-face contact may be preferable for achieving optimal response and completion rates among surgeons. Further work from this study will focus on the individual results for each specialty and examining whether altering ethnicity status in vignettes had any effect on scoring behaviour.

Activities of Daily Living↗
PubMed2006

Criteria for prioritising access to healthcare resources in New Zealand during an influenza pandemic or at other times of overwhelming demand.

During overwhelming demand for resources, such as during an influenza pandemic, clinicians may be required to deny some patients access to a resource (for example ventilation, or hospital admission). However, no pragmatic guidance exists to help clinicians do this. This paper presents criteria for the prioritisation of access to resources during overwhelming demand. The criteria are in the form of eight questions related to the resource and the patients competing for it and are intended to be sufficiently comprehensive and sufficiently succinct to be useful to clinicians who might be required to make such decisions.

Disease Outbreaks↗
PubMed2004

Clinical prioritisation for curative radiotherapy: a local waiting list initiative.

AIMS: Waiting time for radiotherapy is a major problem in radiation oncology practice. The aim of this paper is to present the experience of the Peter MacCallum Cancer Centre in trialling a number of strategies to reduce patient waiting times. MATERIALS AND METHODS: All patients starting megavoltage radiotherapy with curative intent in three separate 1-week blocks had their waiting times recorded. The cohorts were each 8 weeks apart and were before (September), during (November) and after (January) the introduction of a priority points system. RESULTS: Median waiting time was 35 days in September, 42 days in November and 31 days in January. The number of extremely long waits (>90 days) decreased to 1 by January. Significantly more patients were pre-booked for treatment in January (27/51) compared with September (17/65; P = 0.003) and November (12/65; P < 0.001). Pre-booked patients had shorter waiting times compared with patients who was not pre-booked (P < 0.0001). Difficulties at one particular treating location contributed to the longer median waiting times in November. Although there had no significant difference in waiting time in non-breast unit patients between the three cohorts, there was a decrease in waiting times in breast unit patients, especially between November and January (P = 0.0008). There was no significant increase in delay to starting treatment in other treating units, resulting in more equitable access across all units. CONCLUSIONS: A combination of encouraging pre-booking and the introduction of a priority points system has led to a decrease in waiting times, especially among breast unit patients.

Appointments and Schedules↗
PubMed2005

Equity in health care prioritisation: an empirical inquiry into social value.

The value of QALY gains for different patients may be recalculated using equity weights, but it is unclear which interpretation of equity should be used: severity of illness, fair innings or proportional shortfall. We set up an experiment to analyze which of these equity concepts best reflects people's distributional preferences. Sixty respondents assigned a priority rank to the treatment of 10 conditions using the paired comparison technique. We described these real-life conditions by their actual QALY profiles, i.e. in terms of age, disease free period, duration of disease, quality of life, and life years lost. Next we determined the priority rank order of the 10 conditions by the three equity concepts, using the weights that each equity concept attributes to the different units of the QALY profile describing the 10 conditions. To explore the social interpretation of equity, we compared the observed and theoretical rank orderings using Spearman correlations. All correlations were significant at a 0.05 level. Fair innings best predicted the observed rank order of the 10 conditions (r=0.95). Weaker correlations were found for proportional shortfall (r=0.82) and severity of illness (r=-0.65). This result calls attention to health policy, because actual health care decisions often reflect concerns of severity of illness. This raises the question if health care decision makers evaluate the claims of different patients for health care by appropriate criteria.

Aged↗
PubMed2005

Effects of attentional prioritisation on the temporal and spatial components of an interlimb circle-drawing task.

This study aimed to examine the effects of directing attention to the spatial dimension of the circle-drawing task on interlimb coordination patterns across limbs. Eighteen participants performed a circle-drawing task involving in-phase and antiphase coordination modes under upper limb, contralateral and ipsilateral limb combinations. Results indicated that (a) coordination pattern stability co-varied with central cost when attentional focus was directed to the spatial dimensions of the interlimb circle-drawing task; (b) attentional focus on the spatial components modified the inherent performance asymmetries between the limbs; (c) finally, attention to the spatial components of the interlimb circle-drawing task modulated movement trajectories and at the same time the stability of temporal coordination.

Adolescent↗
PubMed2004

Prioritising and planning of urban stormwater treatment in the Alna watercourse in Oslo.

The Oslo municipal Water and Sewage Works (VAV) intends to improve the water quality in the Alna watercourse, in particular, with regards to the biological diversity. In order to reduce existing discharges of polluted urban stormwater, a study has been carried out to rank subcatchment areas in descending order of magnitude and to assess possible measures. An overall ranking methodology was developed in order to identify and select the most suitable subcatchment areas for further assessment studies (74 subcatchment/drainage areas). The municipality's comprehensive geographical information system (GIS) was applied as a base for the ranking. A weighted ranking based on three selected parameters was chosen from several major influencing factors, namely total yearly discharge (kg pollution/year), specific pollution discharge (kg/area/year) and existing stormwater system (pipe lengths/area). Results show that the highest 15 ranked catchment areas accounted for 70% of the total calculated pollution load of heavy metals. The highest ranked areas are strongly influenced by three major highways. Based on the results from similar field studies, it would be possible to remove 75-85% of total solids and about 50-80% of heavy metals using wet detention ponds as Best Available Technology (BAT). Based on the final ranking, two subcatchment areas were selected for further practical assessment of possible measures. VAV plans to use wet detention ponds, in combination with other measures when relevant, to treat the urban runoff. Using calculated loading and aerial photographs (all done in the same GIS environment), a preliminary sketch design and location of ponds were performed. The resulting GIS methodology for urban stormwater management will be used as input to a holistic and long-term planning process for the management of the watercourse, taking into account future urban development and other pollution sources.

Cities↗
PubMed2005

Rapid assessment for prioritisation of trachoma control at community level in one district of the Kaolack Region, Senegal.

The objective of this study was to use a modified Lot Quality Assurance Sampling methodology to classify communities according to prevalence of active trachoma and to estimate the prevalence of trachoma and trichiasis in Nioro department, Kaolack Region, Senegal. A survey was conducted using two-stage cluster sampling to select 50 children aged 2-5 years in each of 33 clusters. In total 1,648 children were examined for active trachoma. Information on trachoma risk factors was collected through interviews with the mother or the household head of the child. Adults (>40 years) with trichiasis were identified through case finding. Nineteen clusters had a low prevalence of active trachoma in children aged 2-5 years (<20%), 11 had medium prevalence (20-40%) and three had high prevalence (>40%). The prevalence of active trachoma in children aged 2-5 years was 17.4% (95% CI 12.9-21.8%). Multivariate-adjusted predictors of active trachoma were: age, facial cleanliness, hygiene practices and keeping cattle in the household. The prevalence of trichiasis in adults aged over 40 years was 1.77% (95% CI 1.24-2.51), equating to 985 adults (95% CI 765-1250) with trichiasis in Nioro department. In conclusion, a survey using rapid methodology showed that trachoma is a problem of public significance in Nioro department, Senegal.

Child, Preschool↗
PubMed2003

Clinical and lay preferences for the explicit prioritisation of elective waiting lists: survey evidence from Wales.

Waiting lists are a persistent feature of public health care systems. The United Kingdom National Health Service (NHS) is considering priority scoring systems as a means of ensuring that patients are treated according to clinical need rather than maximum waiting time targets. Our objective was to elicit the preferences of those involved in the finance, delivery and receipt of elective health care regarding the clinical and social factors that should and should not determine waiting time. We conducted a postal survey of 750 general practitioners, 500 consultants, 29 health authority commissioners and 1000 members of the general public across Wales. We found both professional and lay support for a more explicit system of rationing access to elective health care by waiting list. The majority of each of the survey groups believe that level of pain, rate of deterioration of disease, level of distress and level of disability should play the most influential role in determining waiting times. They agree that age, ability to pay, cost of treatment, evidence of cost-effectiveness, existence of dependants, and self-inflicted ill health should have little or no influence on patient priority. In conclusion, were the NHS to widen its use of waiting list priority scoring systems, our study suggests that there may be some degree of consensus as to the criteria to be used.

Attitude of Health Personnel↗
PubMed1999

Prioritising family health needs: a time--space analysis of women's health-related behaviours.

Much has been made over the years of the view that health-related geographical research has failed fully to explore the complex and mutually reinforcing impact of social and spatial relations on individual health-related behaviours. At the same time, there is a growing awareness elsewhere in the social sciences and in health services research of the generally inadequate exploration of the role of place particularly at the scale of the local community--in the social construction of health, illness and health care use. This paper aims to contribute to the debate by offering a clear framework within which to analyse the impact of spatially configured social relations at the micro-level. In-depth interview evidence from Liverpool shows that, looking at the problem from the perspective of the opportunity-costs of time-space constraints, is a useful means to understand the distinct ways in which health services are used, when and why, across different social groups and geographical areas. Particular attention is drawn to the different thresholds for decision-making depending upon whose health-related needs are being negotiated within the family. The paper concludes with the latest policy developments in UK primary care which offer professionals the clear opportunity to develop much more sophisticated understandings of what constitutes locally-sensitive health service provision. The argument is that such developments must be based on a firm sense of how individual time-space circumstances interact with conditions in the local area if the best possible use of increasingly scarce and valuable resources is to be achieved--particularly in communities characterised by poverty and social exclusion such as those in Liverpool.

Adult↗
PubMed2002

Prioritising objectives for waste reprocessing: a case study in secondary lead refining.

Secondary lead refining produces a sulphidic slag that also contains varying quantities of lead. Initially, the objectives of this project were to treat the slag in order to recover the valuable lead as well as to render the slag environmentally benign. However, in keeping with the principles of clean technology and, specifically, the approach of clean production, the project was redefined with the following priorities: waste characterisation; waste minimisation through process improvement; waste modification; identification of slag treatment methods. Characterisation of the waste facilitated an overall process understanding and aided in identifying process deficiencies. Process improvement was aimed at reducing both the quantity of slag produced as well as the lead loss to the slag. Waste characterisation combined with local hazardous waste regulations enabled desirable waste modifications to be identified. These waste adaptations were implemented through process modification. Lastly, treatment methods for the slag were identified.

Humans↗
PubMed2003

Factors that contribute to quality of life outcomes prioritised by people with multiple sclerosis.

The aim was to investigate factors associated with depression and social function, two outcomes identified as important by people with multiple sclerosis (MS) and to identify underlying dimensions of psycho-social well-being that may be useful as outcome measures. People with MS in eight randomly selected health authorities/boards in England and Scotland completed a postal questionnaire relating to preferences and needs for their health and social care, along with the Beck Depression Inventory and the SF-36. Responses to 10 of the original items were subjected to factor analysis. These and other explanatory variables were entered into multivariable regression models for the two outcomes. The factor analysis resulted in three dimensions representing different aspects of psycho-social well-being; one of these (representing autonomy) was associated with improvements in both outcomes, as was the SF-36 emotional role limitation score. Three other SF-36 dimensions and lack of contact with a health professional in the last year were related just to social function. The regression models emphasise the value of enabling autonomy and self-reliance amongst people with MS, as well as more general measures of emotional health. The present work identifies specific questions that could be used to measure pivotal aspects of an individual's psycho-social well-being. While these findings warrant replication for people with MS, they may have relevance to those with other long-term illnesses.

Adult↗
PubMed2001

Prioritising quality.

The deluge of new initiatives, proposals and recommendations for solving the problems required to improve patient safety and quality of health care continues unabated. Implementing the proposed solutions for improving patient safety and quality of care requires setting priorities for action throughout the different levels of the health-care system. Currently, we face the dilemma of having to set priorities from the plentiful themes that are intuitively sensible and well accepted. There is an increasing number of examples of using systematic processes which contain explicit and transparent criteria for priority setting in patient safety and quality initiatives. These should be more widely adopted and become a key requirement for all future proposals for improving patient safety and quality of health care.

Australia↗