This article examines the role of health governance in shaping the outcomes of healthcare reforms in China. The analysis shows that the failure of reforms during the 1980s and 1990s was in part due ...to inadequate attention to key aspects in health governance, such as strategic interactions among government, providers and users, as well as incentive structures shaping their preferences and behaviour. Although more recent reforms seek to correct these flaws, they are insufficiently targeted at the fundamental governance problems that beset the sector. The article suggests that the Chinese government needs to heighten its efforts to enhance health governance and change the ways providers are paid if it is to succeed in achieving its goal of providing health care to all at affordable cost.
In Sweden, migrants have poorer sexual and reproductive health compared to the general population. Health literacy, in the form of the cognitive and social skills enabling access to health promoting ...activities, is often poorer among migrants, partly due to language and cultural barriers. Culturally sensitive health education provides a strategy for enhancing health literacy. Since 2012, specially trained civic and health communicators have provided sexual and reproductive health and rights information to newly arrived refugees in Skåne, Sweden. The aim of this study was to explore how information on sexual and reproductive health and rights was perceived by female recipients and whether being exposed to such information contributed to enhanced sexual and reproductive health and rights literacy. Semi-structured in-depth interviews were conducted with nine women and analysed using qualitative content analysis. Two themes emerged: (1) opening the doors to new understandings of sexual and reproductive health and rights and (2) planting the seed for engagement in sexual and reproductive health and rights issues, illustrating how cultural norms influenced perceptions, but also how information opened up opportunities for challenging these norms. Gender-separate groups may facilitate information uptake, while discussion concerning sexual health norms may benefit from taking place in mixed groups.
Using survey data from the 2009 wave of the European Union Statistics on Income and Living Conditions, this study examines the determinants of unmet needs for medical and dental care in European ...countries. Special emphasis is put on the impact of health system characteristics. Four factors are taken into account: the density of doctors or dentists, the rules governing access to practitioners, the method of paying primary care physicians, and the amount of out-of-pocket payments. The analysis is carried out using multilevel logistic regression models. Separate regressions are estimated for medical and dental services. The dependent variable is whether respondents reported that, at least once in the last 12 months, they needed care but did not receive it. The estimation results show that the probability of experiencing unmet medical or dental needs varies noticeably across countries. This intercountry variability seems to be partly explained by the differences in the financing of health care. Indeed, a positive link is found between the share of households' out-ofpocket payments in total health expenditure and the probability of unmet needs. The other contextual factors do not seem to play a significant role.
To address macro-social and economic determinants of health and equity, there has been growing use of intersectoral action by governments around the world. Health in All Policies (HiAP) initiatives ...are a special case where governments use cross-sectoral structures and relationships to systematically address health in policymaking by targeting broad health determinants rather than health services alone. Although many examples of HiAP have emerged in recent decades, the reasons for their successful implementation—and for implementation failures— have not been systematically studied. Consequently, rigorous evidence based on systematic research of the social mechanisms that have regularly enabled or hindered implementation in different jurisdictions is sparse. We describe a novel methodology for explanatory case studies that use a scientific realist perspective to study the implementation of HiAP. Our methodology begins with the formulation of a conceptual framework to describe contexts, social mechanisms and outcomes of relevance to the sustainable implementation of HiAP. We then describe the process of systematically explaining phenomena of interest using evidence from literature and key informant interviews, and looking for patterns and themes. Finally, we present a comparative example of how Health Impact Assessment tools have been utilized in Sweden and Quebec to illustrate how this methodology uses evidence to first describe successful practices for implementation of HiAP and then refine the initial framework. The methodology that we describe helps researchers to identify and triangulate rich evidence describing social mechanisms and salient contextual factors that characterize successful practices in implementing HiAP in specific jurisdictions. This methodology can be applied to study the implementation of HiAP and other forms of intersectoral action to reduce health inequities involving multiple geographic levels of government in diverse settings.
Pour répondre aux facteurs macroéconomiques et sociaux de la santé et de l’équité, les gouvernements utilisent de plus en plus les interventions intersectorielles dans le monde entier. Les initiatives de la Santé dans toutes les politiques (STP) sont des cas particuliers pour lesquels les gouvernements utilisent les structures et les relations intersectorielles pour systématiquement mettre en avant la santé dans la politique en ciblant les facteurs déterminants de la santé au sens large plutôt que les services de santé seuls. Bien que, depuis ces dix dernières années, de nombreux exemples de STP existent, les raisons de la réussite ou de l’échec de leur application n’ont pas été systématiquement étudiées. Par conséquent, il existe trop peu de données rigoureuses provenant des recherches systématiques sur les différents mécanismes sociaux qui ont régulièrement permis ou entravé l’application de la STP dans les différentes juridictions. Nous décrivons une nouvelle méthodologie pour des études de cas explicatives en utilisant une perspective scientifique réaliste afin d’étudier l’application de la STP. Dans notre méthodologie, nous commençons par définir un cadre conceptuel pour décrire le contexte, les mécanismes sociaux et les résultats pertinents d’une mise en oeuvre durable. Ensuite nous décrivons le processus qui permet de systématiquement expliquer les phénomènes ayant un intérêt en utilisant de la documentation, en interviewant des acteurs clés et en recherchant des tendances et des thèmes. Et pour finir, nous présentons un exemple comparatif pour comprendre comment l’outil d’évaluation de l’impact sur la santé a été utilisé en Suède et au Québec ce qui a permis d’illustrer comment cette méthodologie se sert de preuves concrètes pour tout d’abord décrire les mises en oeuvre réussies de la STP et puis enfin pour affiner le cadre conceptuel initial. Notre méthodologie aide les chercheurs à identifier et à trianguler les nombreuses preuves décrivant les mécanismes sociaux et les facteurs contextuels essentiels qui caractérisent une mise en pratique efficace de la STP dans des juridictions spécifiques. Cette méthodologie peut être appliquée pour étudier la mise en pratique de la STP ainsi que toute autre forme d’intervention ayant pour but de réduire les inégalités intersectorielles impliquant de multiples niveaux géographiques de gouvernements dans des milieux variés.
为了解决医疗在宏观社会和经济层面的因素与公平之间的关 系，世界各国政府越来越多得开始采用跨领域的行动。所有 政策中的医疗 （HiAP）倡议就是一个这样的例子，不仅仅关 注医疗服务，在这里政府采用跨领域结构和关系通过分析影 响医疗的广泛因素来系统得针对政策制定过程中的医疗部 分。尽管在近几十年来出现了类似 HiAP 这样的组织，这些 组织的成功实施（失败实施）还没有被系统地研究过。因 此，我们缺少通过对不同管辖范围使实施成功或失败的社会 机制的系统研究得出的严谨证据。在本文中我们采用了一个 新的解释性个案研究的方法论，这个方法论采用的是一种科 学现实主义视角来研究HiAP 的实施。我们的方法论首先构 建了一个概念框架来描述背景、社会机制、HiAP 实施的可持 续性相关结果。然后，我们对使用文献和知情人物访谈得到 的证据系统解释相关现象的过程进行了描述，并寻找模式和 主题。最后，我们展示出在瑞典和魁北克是如何使用健康影 响评估工具来阐释这个方法论是如何描述 HiAP 成功实施的 例子，之后完善最初的框架。我们所描述的这个方法论可以 帮助研究者确认和测量在某一特定领域促使 HiAP 实施成功 的社会机制和显著的环境因素的大量证据。这个方法论可以 被用于研究HiAP 的实施以及其他在不同环境中多地域政府 为减少医疗不公平所采取的跨领域行动。
Para hacer frente a los determinantes macro-sociales y económicos de la salud y la equidad, ha habido una creciente utilización de la acción intersectorial por parte de los gobiernos alrededor del mundo. Las iniciativas de Salud en Todas las Políticas (SeTP) son un caso especial en el que los gobiernos utilizan estructuras y relaciones intersectoriales para abordar sistemáticamente la salud en la formulación de políticas al enfocarse en los determinantes generales de la salud y no en los servicios de salud por sí solos. Aunque muchos ejemplos de SeTP han surgido en las últimas décadas, las razones de su exitosa implementación - y de los fracasos en la implementación- no se han estudiado de manera sistemática. En consecuencia, la evidencia rigurosa basada en la investigación sistemática de los mecanismos sociales que han permitido u obstaculizado de forma regular la implementación en las distintas jurisdicciones es escasa. Se describe una nueva metodología para el estudio de casos explicativos que utilizan una perspectiva científica realista para estudiar la implementación de la SeTP. Nuestra metodología comienza con la formulación de un marco conceptual para describir contextos, mecanismos sociales y los resultados relevantes para la implementación sostenible de la SeTP. A continuación describimos el proceso de explicar sistemáticamente el fenómeno de interés, utilizando la evidencia de la literatura y entrevistas con informantes claves, y buscando patrones y temas. Por último, se presenta un ejemplo comparativo de cómo se han utilizado las herramientas de Evaluación del Impacto Sanitario en Suecia y Quebec para ilustrar cómo esta metodología utiliza evidencia para primero describir las prácticas exitosas para la implementación de la SeTP y luego afinar el marco inicial. La metodología que describimos ayuda a los investigadores a identificar y triangular evidencia rica que describe los mecanismos sociales y los factores contextuales más destacados que caracterizan a las prácticas exitosas en la implementación de la SeTP en jurisdicciones específicas. Esta metodología puede ser aplicada al estudiar la implementación de la SeTP y otras formas de acción intersectorial para reducir las inequidades en la salud que conllevan múltiples niveles geográficos de gobierno en diversos entornos.
In most parts of the world, men access health services less frequently than women, and this trend is unrelated to differences in need for services. While male involvement in healthcare as partners or ...fathers has been extensively studied, less is known about the health-seeking behavior of men as clients themselves. This interventional research study aimed to determine how the introduction of male-friendly clinics impacted male care-seeking behavior and to describe the reasons for accessing services among men in rural Kenya.
We questioned men to assess utilization and perceptions of existing health clinics, then designed and evaluated a "male clinics" intervention where dedicated male health workers were hired for one year to offer routine, free services exclusively to men within existing healthcare facilities. Results were compared between data from Male Clinics in specific health facilities, the same facilities concurrently, nearby control facilities concurrently, and intervention facilities historically. Costs of services, distance to facilities, and quality of care were the main barriers to healthcare access reported. The number of total visits was significantly higher than control groups (p<0·0001). In the intervention group, 18·6% of visits were for a checkup compared to almost none in control groups. The most common diagnoses overall were upper respiratory tract infections, malaria and injury. A major limitation of this study is the non-comparability in information captured using the Male Clinic registers compared to control registers.
Costs and quality of services deter men from seeking healthcare. The introduction of male-friendly health services could encourage men to seek preventive care and increase service uptake.
By the end of the eighteenth century, Peru had witnessed the decline of its once-thriving silver industry, and it had barely begun to recover from massive population losses due to smallpox and other ...diseases. At the time, it was widely believed that economic salvation was contingent upon increasing the labor force and maintaining as many healthy workers as possible. InMedicine and Politics in Colonial Peru,Adam Warren presents a groundbreaking study of the primacy placed on medical care to generate population growth during this era.
The Bourbon reforms of the eighteenth century shaped many of the political, economic, and social interests of Spain and its colonies. In Peru, local elites saw the reforms as an opportunity to positively transform society and its conceptions of medicine and medical institutions in the name of the Crown. Creole physicians in particular, took advantage of Bourbon reforms to wrest control of medical treatment away from the Catholic Church, establish their own medical expertise, and create a new, secular medical culture. They asserted their new influence by treating smallpox and leprosy, by reforming medical education, and by introducing hygienic routines into local funeral rites, among other practices.
Later, during the early years of independence, government officials began to usurp the power of physicians and shifted control of medical care back to the church. Creole doctors, without the support of the empire, lost much of their influence, and medical reforms ground to a halt. As Warren's study reveals, despite falling in and out of political favor, Bourbon reforms and creole physicians were instrumental to the founding of modern medicine in Peru, and their influence can still be felt today.
ABSTRACT
BACKGROUND
We examined racial/ethnic disparities in school‐based behavioral health service use for children with psychiatric disorders.
METHODS
Medicaid claims data were used to compare the ...behavioral healthcare service use of 23,601 children aged 5‐17 years by psychiatric disorder (autism, attention deficit hyperactivity disorder ADHD, conduct/oppositional defiant disorder, and “other”) and by race/ethnicity (African‐American, Hispanic, white, and other). Logistic and generalized linear regression analyses were used.
RESULTS
Differences in service use by racial/ethnic group were identified within and across diagnostic groups, both for in‐school service use and out‐of‐school service use. For all disorders, Hispanic children had significantly lower use of in‐school services than white children. Among children with ADHD, African‐American children were less likely to receive in‐school services than white children; however, there were no differences in adjusted annual mean Medicaid expenditures for in‐school services by race/ethnicity or psychiatric disorders. Statistically significant differences by race/ethnicity were found for out‐of‐school service use for children with ADHD and other psychiatric disorders. There were significant differences by race/ethnicity in out‐of‐school service use for each diagnostic group.
CONCLUSIONS
Differences in the use of school‐based behavioral health services by racial and ethnic groups suggest the need for culturally appropriate outreach and tailoring of services to improve service utilization.
The objective of this study was to assess trends in health insurance coverage, health service utilization, and health care access among working-age adults with and without disabilities before and ...after full implementation of the Affordable Care Act (ACA), and to identify current disability-based disparities following full implementation of the ACA. The ACA was expected to have a disproportionate impact on working-age adults with disabilities, because of their high health care usage as well as their previously limited insurance options. However, most published research on this population does not systematically look at effects before and after full implementation of the ACA. As the US Congress considers new health policy reforms, current and accurate data on this vulnerable population are essential. Weighted estimates, trend analyses and analytic models were conducted using the 1998-2016 National Health Interview Surveys (NHIS) and the 2014 Medical Expenditure Panel Survey. Compared with working-age adults without disabilities, those with disabilities are less likely to work, more likely to earn below the federal poverty level, and more likely to use public insurance. Average health costs for this population are 3 to 7 times higher, and access problems are far more common. Repeal of key features of the ACA, like Medicaid expansion and marketplace subsidies, would likely diminish health care access for working-age adults with disabilities.
Abstract
India has announced the ambitious program to transform the current primary healthcare facilities to health and wellness centres (HWCs) for provision of comprehensive primary health care ...(CPHC). We undertook this study to assess the cost of this scale-up to inform decisions on budgetary allocation, as well as to set the norms for capitation-based payments. The scale-up cost was assessed from both a financial and an economic perspective. Primary data on resources used to provide services in 93 sub-health centres (SHCs) and 38 primary health care centres (PHCs) were obtained from the National Health System Cost Database. The cost of additional infrastructure and human resources was assessed against the normative guidelines of Indian Public Health Standards and the HWC. The cost of other inputs (drugs, consumables, etc.) was determined by undertaking the need estimation based on disease burden or programme guidelines, standard treatment guidelines and extent and pattern of care utilization from nationally representative sample surveys. The financial cost is reported in terms of the annual incremental cost at health facility level, as well as its implications at national level, given the planned scale-up path. Secondly, economic cost is assessed as the total annual as well as annual per capita cost of services at HWC level. Bootstrapping technique was undertaken to estimate 95% confidence intervals for cost estimations. Scaling to CPHC through HWC would require an additional ₹ 721 509 (US$10 178) million allocation of funds for primary healthcare >5 years from 2019 to 2023. The scale-up would imply an addition to Government of India’s health budget of 2.5% in 2019 to 12.1% in 2023. Our findings suggest a scale-up cost of 0.15% of gross domestic product (GDP) for full provision of CPHC which compares with current public health spending of 1.28% of GDP and a commitment of 2.5% of GDP by 2025 in the National Health Policy. If a capitation-based payment system was used to pay providers, provision of CPHC would need to be paid at between ₹ 333 (US$4.70) and ₹ 253 (US$3.57) per person covered for SHC and PHC, respectively.
Abstract
In sub-Saharan African countries, out-of-pocket payments can be a major barrier to accessing appropriate healthcare services. Community-based health insurance (CBHI) has emerged as a ...context-appropriate risk-pooling mechanism to provide some financial protection to populations without access to formal health insurance. The aim of this rapid review was to examine the peer-reviewed literature on the impact of CBHI on the use of healthcare services as well as its capacity to improve equity in the use of healthcare between different socio-economic groups. A systematic search of three electronic databases (Pubmed, Cochrane Library and Littérature en Santé) was performed. Data were extracted on scheme and study characteristics, as well as the impact of the schemes on relevant outcomes. Sixteen publications met the inclusion criteria, studying schemes from seven different countries. They provide strong evidence that community-based health insurance can contribute to improving access to outpatient care and weak evidence that they improve access to inpatient care. There was low evidence on their capacity to improve equity in access to healthcare among insured members. In the absence of sufficient public spending for healthcare, such schemes may be able to provide some valuable benefits for communities with limited access to primary-level care in sub-Saharan Africa. The overall high risk of bias of the studies and the wide existing variety of insurance arrangements suggest caution in generalizing these results. These findings need to be validated and further developed by rigorous studies.
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