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PubMed1994

Privatization of the medical market in socialist China: a historical approach.

A Socialist-Market Economy was defined as a target model for China's economic reform by China's 14th National Congress in 1992. Such an innovative change in China's more than a decade long economic reform has brought both new challenges and opportunities for its health care system reform as it moves toward a market determination mechanism and involvement of the private sector. A better understanding of the nature and history of the Chinese private medical market and its dynamic socio-economic environment would certainly shed a great deal of light onto the accomplishments of the health care reform. Research in this area, however, is almost non-existent at either national or international levels. The present study attempts to fill this gap by providing a comprehensive assessment of both historical and prospective development of the Chinese private medical market. Three stages are defined to present the tortuous development of this market over the last four decades, coupled with our critiques of the underlying merits and problems. Predictions are also made on the future perspective of the private market, and its possible impact and role in shaping the reform of the entire Chinese health care system. The government's role as well as its future strategy to cope with the issues surrounding Chinese health care reform are also summarized. The study concludes with five health policy recommendations aimed at facilitating China's health care reform via more market-oriented determination of resources allocation, production, and distribution, coupled with promotion of the private sector's involvement while minimizing its potential adverse side effects.

Ambulatory Care Facilities↗

PubMed1995

A survivor's guide to programme budgeting.

In this paper a descriptive account is given of programme budgeting in the Hastings and Rother localities of East Sussex Health Authority. The primary purpose of the exercise was to track past resource consumption in a comprehensive and overlapping matrix of programmes, with a view to simplifying past annual expenditure into a single matrix, informing the health authority of the overall pattern of resource consumption, planning future expenditure, co-ordinating the strategic plans and purchasing intentions of all those involved in commissioning health care, and communicating the health authority's view of past and future spending. Many of the findings gave new insights and led either to changes in resource allocation or to plans for future study. They have proved to be a useful tool for communication and education, especially with providers of health care and public representative bodies. The process will now feed into long-term strategic planning and short-term purchasing intentions. Marginal analysis is now being undertaken in a number of clinical specialties and disease areas. The cumulative effect of a series of planned investment and disinvestment decisions can be tested against agreed priorities for programmes before final decisions are taken. Thus, programme budgeting can be a powerful tool in the commissioning process and should be within the capabilities of even the smallest health authorities.

Budgets↗

PubMed1987

The economics of schistosomiasis chemotherapy.

The optimal choice o f chemotherapy regime arises in the design o f every schistosomiasis control programme. This choice is o f particular contemporary interest for two reasons. At one extreme the development of effective single-dose oral drugs such as praziquantel and oxamniquine makes mass chemotherapy a practical option. At the other extreme there has been a revival o f advocacy for some form o f selective treatment. But all developing countries that contemplate schistosomiasis control face severe budget constraints, requiring careful analysis o f the economics o f chemotherapy. In this article, Nick Prescott presents a generalized framework For resource allocation in schistosomiasis chemotherapy, demonstrating that the optimal choice o f chemotherapy regime depends critically on the level of budget constraint, the unit costs o f screening and treatment, and rates o f compliance with screening and chemotherapy-all factors which are usually neglected in the choice o f control strategy.

Journal Article↗

PubMed1983

Health care in the developing world: the role of economists and economics.

This paper does not address itself to high theory or to complex methodologies; nor does it offer any detailed illumination of key economic concepts. Rather, it focuses on the role of economists and economics (not the same thing) in the formulation of health policies, and in influencing an evaluation of health strategies appropriate to the requirements of the developing world. The paper argues that the 'climate' has changed sufficiently in the developing world to promote a close interest in the economics of health and health care. Evidence exists of a growing willingness to employ economists and economic analysis to resource allocation issues within the health sector. Accordingly, a glossary of economic concepts in presented to demonstrate that economics does possess certain ideas, distinct from other disciplines, which can be of considerable value to health planners and health managers alike. The text also sets out, in tabular form, many of the key questions that should be of close interest to policy-makers, and indicates the economic concepts and techniques that can be applied. At the same time, it is noted that there are very real conceptual and methodological problems likely to be faced by those wishing to apply economic reasoning to the health sector. The paper then moves on from analysis to consider implementation, and investigates the political constraints and institutional barriers to the acceptance of economic analysis in the health sector. In the past, the nature of the economics of health has sometimes been considered improper, i.e. views have been expressed that services should be made available to those for whom they may be beneficial, as a matter of right without regard to economics.(ABSTRACT TRUNCATED AT 250 WORDS)

Delivery of Health Care↗

PubMed1983

Psychiatric hospitalization in Poland.

An overview of psychiatric hospitalization in Poland is presented in the context of Polish political and socio-cultural developments. The areas addressed include: the characteristics of the patient population; the organization of Polish mental health service; the nature of psychiatric treatment; psychiatric legislation; patients' rights; and the training and social status of the various mental health professionals. In spite of the meager resources allocated to mental health services, and the consequent staff shortages and overcrowded, drab living conditions in psychiatric facilities, the care afforded patients is generally humane and nonoppressive. Polish psychiatry has succeeded in maintaining its professional autonomy and has assumed a leadership role in the modernization of its service delivery system.

Commitment of Persons with Psychiatric Disorders↗

PubMed1983

The use and misuse of cost-effectiveness analysis.

Cost-effectiveness analysis is indeed a necessary and useful tool to determine optimal resource allocation within the health field. Misuse of the simple CE ratio has however led to incorrect decisions. CE ratios cannot be correctly employed in the following instances: (1) With regard to any program which will result in price changes especially of input factors in the economy; (2) Whenever the total cost or the total quantity of outputs varies among projects; (3) To calculate marginal changes in project size unless data specific to the project size is available, i.e. the planner cannot assume constant costs will prevail in expanding projects. The cost-effectiveness tool has clear advantages over the previously used and time consuming cost-benefit analysis. Not only does cost-effectiveness require less computation but it requires fewer assumptions concerning intangibles which tend to be concentrated on the benefits side. Lastly, this analysis has a useful duality in that any solution unambiguously tells you the least total cost of reaching a given outcome and simultaneously gives you the maximum output for that total cost sum of money.

Cost-Benefit Analysis↗

PubMed1984

Primary health care in practice: a study in Mozambique.

This study investigates the delivery of all aspects of Primary Health Care (PHC) in a case study of one urban health centre in Maputo, Mozambique. Within the context of overall social and economic change, Mozambique has given priority to primary health care as the driving force in its newly developed National Health Service. The urban and rural health centres are intended to be the principal vehicles for PHC delivery, and in this study one of Maputo's recently opened health centres was investigated by observing all clinic sessions, interviewing all health centre workers and collecting data from health centre records. It was found that a dichotomy exists between the tasks ascribed to the health centre in the PHC framework, and the feasibility of their execution given existing personnel and material resources. This derives in part from lack of involvement of PHC practitioners in the organisation and planning of PHC, plus resource allocation which remains in favour of secondary and tertiary rather than primary care. Prevention is accorded priority in PHC theory, yet investigation showed that the major demand on the health centre is for curative care. The quality of both curative and preventive care was evaluated and the need for training in specialist diagnostic skills, and a more socially-based understanding of the determinants of health status and risk emerged, respectively for the groups of workers in the two sectors. The level of contact between the curative and preventive sectors was investigated as was the integration of the health centre into the health service as a whole. The problems arising in these areas must be viewed in the context of the very recent development of a National Health Service in a country where, previously, curative care was available only in urban areas and virtually no preventive programmes existed. This study shows that significant steps are being taken to develop a comprehensive PHC programme in Maputo. More important still will be the extension of this level of care provision to the country as a whole.

Adolescent↗

PubMed1988

Building the infrastructure for primary health care: an overview of vertical and integrated approaches.

In the past four decades there has been a succession of different approaches to the development of infrastructure for the delivery of health services. There have been striking similarities among these approaches in both direction and timing in many different countries, particularly in the developing world. While the general trend has been strongly in the direction of a more comprehensive, integrated health infrastructure, there have been important regressions from this path. It is suggested that the recent attention given to the delivery of 'selective' packages of interventions has often diverted energy and resources from the essential task of developing comprehensive, efficient and effective health services. This paper begins with an historical review of trends in the development of health services infrastructure in recent decades. It proceeds to analyse the implications for the organization of health services and for resource allocation when the health services infrastructure is viewed as part of a health system based on primary health care. Finally, we maintain that district health systems based on primary health care provide an excellent practical model for health development, including an appropriate health system infrastructure. Within this model the concerns with accelerating the application of known and effective technologies and the concerns with strengthening of community involvement and intersectoral action for health are both accommodated. The district health system provides a realistic setting for dialogue and planning involving both professionals and non-professionals concerned with health and social development.

Developing Countries↗

PubMed1989

The use of QALYs in health care decision making.

This paper seeks to highlight some of the critical issues concerning the use of the Quality Adjusted Life Years (QALYs) to measure the outcome of health care choices, in decisions related to both individual patient care and social resource allocation. Much of the support for the QALY is based on its simplicity as a tool for resolving complex choices. However, it may be the case that the QALY is not sufficiently refined or robust, failing perhaps to take into account some of the critical factors which affect preferences over different health care scenarios.

Chronic Disease↗

PubMed1989

Geographic differences in the use of Veterans Administration hospitals.

This study contrasts the determinants of community hospital utilization with Veterans Administration (VA) hospital utilization using traditional planning variables. The comparisons had some expected and some unanticipated findings. Regional differences in non-VA hospital admissions and bed days are fairly well explained by measures of medical need, provider supply, community alternatives, and sociodemographic characteristics (other than those used as proxies for case mix). However, regional variations in the VA are explained less well by the same classes of variables and the unexplained differences between the two systems do not correspond geographically. This suggests that the two systems have different reasons for regional variation. Further, contrary to expectation, when other predictors are held constant, excess bed capacity in the area does not correlate with lower VA utilization. The study is important as the VA comes under increasing pressure to contain costs. It may well be that the rational planning model attributed to the public sector is less likely to overcome maldistribution than the private sector 'invisible hand'. Policy analysts need to give more attention to the political, bureaucratic determinants of resource allocation before changing eligibility criteria or merging the two systems.

Adult↗

PubMed1989

Differences in the approaches of the doctor, manager, politician and social scientist in health care controversies--hospital case-mix management methods: an illustration of the manager's approach in health care controversies.

Resource allocation methods in health care are one of the major sources of controversies between managers, doctors, politicians and social scientists. In the past 10 years, an important innovation has appeared in hospital management and payment methods: case based systems, the most well known being the Diagnostic Related Group (DRG), that have been used for 5 years by Medicare in the U.S.A. to pay for hospital care. Through the analysis of the diffusion of DRGs in the U.S.A. and in France, we support the idea that DRGs are a typical illustration of the managerial approach to health care. They represent a significant breach in professional autonomy through the introduction of bureaucratic rationality. We also show how scientific controversies are structured by the dynamics of the diffusion of case based management systems.

Analysis of Variance↗

PubMed1992

Maternal health and the measurement trap.

This paper focuses on the contribution of measurement-related factors to the neglect of maternal health in resource allocation for programmes and in public health research. As the recent interest in maternal health has now progressed beyond the need for information primarily for the purpose of advocacy, measurement-related factors have emerged as powerful constraints on programme action. Three outstanding needs for information can be identified: first, to establish the levels and trends of specific maternal health outcomes; secondly, to identify the characteristics and determinants of health outcomes; and thirdly, to monitor and evaluate the effectiveness of programmes designed to influence health outcomes. In order to meet these needs, the emphasis placed on operational research by the current major initiatives in maternal health must be complemented by an equivalent emphasis on methodological studies. The call for improved information by international and national agencies should be made in unison with the call for action. Inadequate information is a reality that has to be faced throughout the world, but particularly in developing countries. The quality, quantity and scope of health-related data are the elements of this inadequacy and may be discussed in terms of four factors: the indicators, the data sources, the measurement techniques, and the conceptual framework. In this paper, the neglect of maternal health and the lack of information are shown to be self-reinforcing and constitute a measurement trap sprung by these four factors. Dismantling this trap has revealed a weak conceptual framework to lie at the very centre. Maternal health has tended to be conceptualized as a discrete, negative state, characterized by physical rather than social or mental manifestations, and by a narrow time-perspective focusing on pregnancy, delivery and the puerperium. The need to broaden this perspective and to develop equally broad operational definitions represent important steps forward that must be taken.

Developing Countries↗

PubMed1995

Geographically-decentralized planning and management in health care: some informational issues and their implications for efficiency.

Geographically decentralized planning and management is an emerging theme within the health sector in many OECD countries. Advocates of decentralization argue that providing greater authority to local decision-making bodies can improve both the technical and allocative efficiency with which health care systems operate. Using concepts drawn from organizational theory and the economics of organizations, we examine the potential of centralized and decentralized planning and management structures to be efficient in light of the informational problems that must be overcome to allocate resources efficiently. We focus in particular on the need to integrate information regarding: (1) the effectiveness and efficiency of alternative clinical interventions and of alternative ways organize the delivery of health care; (2) the needs, values, and preferences in the population; and (3) local circumstances that affect delivery of care across regions. Informational concerns suggest that decentralized structures have greater potential to be efficient. We then briefly discuss some principles for the design of decentralized structures to aid in realizing these potential efficiency gains.

Decision Making, Organizational↗

PubMed1995

Preferences for outcomes in economic evaluation: an economic approach to addressing economic problems.

In this paper we critically appraise the appropriateness and validity from an economic perspective of alternative preference-based approaches to measuring outcomes in economic evaluations of health care interventions. We describe the properties of an outcome measure for economic evaluation to make it compatible with the principles of economics when applied to the problem of resource allocation. We also describe the difference and similarities between the psychometric and the economic approaches for the measurement of outcome. Using these properties we critically appraise the use of QALY and HYE methods of measuring individual and social preferences for health outcome. We argue that the most advanced measure currently available that meets these required properties is the HYE. Because the HYE, unlike the QALY, has its foundations in utility theory under uncertainty, it neither assumes particular formulations of the individual utility function, nor is it incompatible with the principles of economics. As such it represents a further stage in the continuing development of methods for economic evaluation of health care programmes.

Evaluation Studies as Topic↗

PubMed1995

Clinical and public health perspectives and applications of health-related quality of life measurement.

Health-related quality of life (HRQL) measures have been developed from the utilitarian ethical perspective of public health medicine which may be contrasted with individual-centered indicators; these emphasise the unique experience of a patient. The impairment-disability-handicap framework provides a more complete description of disease consequences and health outcomes than a generic HRQL indicator. The assessment of reliability and validity of HRQL indicators is often carried out inappropriately: population repeatability is measured when an indicator will be used to examine changes in individuals; between observer variation may be large compared with variation between populations. Content and construct validity are usually measured but the more important predictive validity is neglected. Effect sizes of HRQL indicators are likely to be inflated by use of between subject estimates of variance but the more appropriate within subject variance is seldom reported. HRQL indicators are of very limited value for many clinical and public health tasks: monitoring health of individuals and populations; evaluating the effects of health and social policy; allocating resources; evaluating the effects of treatment. Alternative methods of assessment derived from the impairment-disability-handicap conceptual framework are preferable.

Effect Modifier, Epidemiologic↗

PubMed1995

Environmental and health-related quality of life: conceptual and methodological similarities.

The recent revival of interest in the concept of quality of life by academics in both the social and medical sciences, and amongst politicians has focused attention on the continuing debate about the definition, measurement and utilisation of quality of life. In particular, the need amongst regulatory and financial authorities--both in the health sector and in local government--to know about the potential impact of intervention has encouraged further interest in the use of quality of life measures to assist resource allocation and assessing the impact of policy decisions. In this paper it is argued that whilst such measures may be the ultimate goal of research, this can only be constructed on a fuller understanding of quality of life measures of current conditions and the relationship between components of life quality. A conceptual framework is developed to show the relationship between the way that quality of life, in both environmental and health-related studies, has been conceived and measured. The strong similarities in both respects are discussed, pointing to the need for heightened interdisciplinary dissemination of research methods and assessments.

Adaptation, Psychological↗

PubMed1995

Public health crises of cities in developing countries.

During the decade and a half after Alma Ata hundreds of projects were started in developing countries to implement the principles of PHC and start community based health care programs in the rural areas of developing countries. Until the past five years urban health was not seen as a special health problem. Population pressure in the rural areas has created shortages of land, food and employment opportunities. These forces have generated major population movements to the urban centres. The population movements have encouraged unprecedented expansion of urban centres. This sudden concentration of large populations in small geographical areas has resulted in the urban health crises of the developing world. The poor who live in the slum areas have no access to adequate health services, they experience frequent epidemics of communicable diseases like cholera, they live within a heavily polluted environment, and their children have very poor health because they are not immunized and are malnourished. The paper agrees with approaches which have been championed by development agencies to address the urban health crises. These approaches propose the reorientation of urban health systems to include adoption of PHC for urban health programs, intersectoral collaboration and extra budgetary support. The paper argues for further strengthening of the reorientation approach by adjusting the development planning model. It is proposed that the urban plan be integrated into the national development plan so that emerging urban health crises can receive special attention in resource allocation.

Adult↗

PubMed1996

Market-oriented health care reforms: trends and future options.

In many (predominantly) publicly financed health care systems market-oriented health care reforms are being implemented or have been proposed. The purpose of these reforms is to make resource allocation in health care more efficient, more innovative and more responsive to consumers preferences while maintaining equity. At the same time, the advances in technology result in a divergence of consumers' preferences with respect to health care and urge society to (re)think about the meaning of the solidarity principle in health care. In this paper we indicate some international trends in health care reforms and explore some potential future options. From an international perspective we can observe a trend towards universal mandatory health insurance, contracts between third-party purchasers and the providers of care, competition among providers of care and a strengthening of primary care. These trends can be expected to continue. A more controversial issue is whether there should also be competition among the third-party purchasers and whether in the long run there will occur a convergence towards some "ideal" model. Although regulated competition in health care can be expected to yield more value for money, it might yield both more efficiency and higher total costs. It has been argued that equity can be maintained in a competitive health care system if we interpret equity as "equal access to cost-effective care within a reasonable period of time". Because the effectiveness of care has to be considered in relation to the medical indication and the condition of the patient, the responsibility for cost-effective care rests primarily with the providers of care. Guidelines and protocols should be developed by the profession and sustained by financial incentives embedded in contracts. It has been argued that the third-party purchasers could start to concentrate on the contracts with the primary care physicians. Contracts with other providers could then be a natural complement to these contracts. Coordinated-care contracts between the third-party purchasers and the consumer of care could provide the consumer with monetary incentives to go to efficient providers. A consumer choice of insurance contract could give the consumer an opportunity to make important choices in health care. However, each society has to make its own choices about what care should be available to everybody independent of an individual's purchasing power.

Community Participation↗