Financial incentives for living kidney donors: are they necessary?

In the face of the perceived failure of altruistic organ donation programs to generate sufficient kidneys to meet demand, introducing financial incentives for living donors is sometimes argued as the only effective strategy by which lives currently lost while awaiting kidney transplantation might be saved. This argument from life-saving necessity is implicit in many incentive proposals, but rarely challenged by opponents. The core empirical claims on which it rests are thus rarely interrogated: that the gap between supply of and demand for donor kidneys is large and growing, the current system cannot meet demand, and financial incentives would increase the overall supply of kidneys and thus save lives. We consider these claims in the context of the United States. While we acknowledge the plausibility of claims that incentives, if sufficiently large, may successfully recruit greater numbers of living donors, we argue that strategies compatible with the existing altruistic system may also increase the supply of kidneys and save lives otherwise lost to kidney failure. We conclude that current appeals to the life-saving necessity argument have yet to establish sufficient grounds to justify trials of incentives.

Risk, regulation, and financial incentives for living kidney donation

In his comprehensive review of the hazards of existing,largely unregulated markets in human kidneys, Koplin(2014) argues that advocates of regulated markets mayunderestimate the potential physical, psychosocial andfinancial harms risked by vendors. He acknowledges, however,that market proponents will likely be undeterred incalling for “trials” or “pilot studies” of financial incentivesin developed countries on the grounds that the experienceof international black markets is of limited predictive valuein anticipating the outcomes of regulated markets. We contendthat there is good evidence to support the concernthat living vendors would be at higher risk of adversehealth outcomes compared to altruistic donors in the contextof a regulated market. This has important implicationsnot only for the informed consent of prospective vendors,but also for the potential regulations that would berequired to mitigate these risks. We argue here that pilotstudies would be at the very least premature until suchtime as market proponents have sufficiently engaged withpotential harms to prospective kidney vendors.

Preparing pre-service teachers for rural teaching: a new approach

In Australia, recruitment of high quality teachers is seen as critical for the future of rural education provision. A national inquiry into rural and remote education conducted in 2000 by HREOC supported this claim stating that there is a crisis for rural schools attracting new teachers and blamed teacher education for not doing enough to equip beginning teachers with the skills and knowledge needed for teaching in rural and remote Australia. Although state governments provide financial incentives for potential graduates to embark on a rural practicum placement, this incentive does not appear sufficient. There is an urgent need in teacher education to consider  alternative ways to generate interest in a rural teaching career. This paper describes a pre-service initiative between the metropolitan Burwood campus of Deakin University and a Victorian rural school community. The initiative was designed to enable a cohort of 45 city-based student teachers studying a particular unit to better understand rural issues, pedagogy and ultimately to foster interest in country teaching.

New money for mental health : will it make things better for rural and remote Australia?

New Australian government funding for the Better Outcomes in Mental Health Care initiative is a significant step forward for mental health, with general practitioners now able to offer direct referrals to psychologists, social workers, occupational therapists and Aboriginal health workers. Incentives for better teamwork between GPs and other mental health professionals have been introduced, but may have unintended consequences, including an exacerbation of workforce shortages in rural and remote areas. Possible solutions to these shortages include rural scholarships for students in the mental health professions; recruitment and retention of students coordinated by university departments of rural health; better access to continuing professional development; and federally funded rural positions and additional financial incentives for rural mental health practitioners.

Enhancing patient engagement in chronic disease self-management support initiatives in Australia : the need for an integrated approach

♦ Although emphasis on the prevention of chronic disease is important, governments in Australia need to balance this with continued assistance to the 77% of Australians reported to have at least one long-term medical condition.

♦ Self-management support is provided by health care and community services to enhance patients’ ability to care for their chronic conditions in a cooperative framework.

♦ In Australia, there is a range of self-management support initiatives that have targeted patients (most notably, chronic disease self-management education programs) and health professionals (financial incentives, education and training).

♦ To date, there has been little coordination or integration of these self-management initiatives to enhance the patient–health professional clinical encounter.

♦ If self-management support is to work, there is a need to better understand the infrastructure, systems and training that are required to engage the key stakeholders — patients, carers, health professionals, and health care organisations.

♦ A coordinated approach is required in implementing these elements within existing and new health service models to enhance uptake and sustainability.

The quality and outcomes framework reduces disparities in health outcomes for cardiovascular disease

Jamie Robinson, the Berkeley health economist, famously remarked in 2001 that ‘the three worst ways to pay doctors are salary, capitation and fee-for-service.’ Different financial incentives produce different clinical and service outcomes, sometimes perversely.1 In 2004, the UK government introduced pay for performance (P4P) for general practitioners, the Quality and Outcomes Framework (QOF). Its introduction was associated with the general trend in the National Health Service away from placing implicit trust in doctors and more active monitoring of their performance. One-quarter of GP pay can be earned from achieving scores on 147 indicators.2 These indicators were acceptable to doctors because the majority are evidence-based clinical outcome measures for 10 chronic diseases. Others relate to patient access and satisfaction, and practice organisation.

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background. The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model.

Methods. A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented.

Results. Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis.

Conclusions. Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community.

What is known about this topic? Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known.

What does this paper add? This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness.

What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.

The rural practicum : preparing a quality teacher workforce for rural and regional Australia

Communities play a critical role in supporting pre-service teachers during rural and regional professional experience. This support, coupled with access to teacher educators and university resources, appears to positively influence graduate attitudes toward taking up a rural appointment. These are among the key findings to emerge from open-ended responses within 263 surveys completed for the Rethinking Teacher Education for Rural and Regional Sustainability—Renewing Teacher Education for Rural and Regional Australia project (TERRAnova). The national surveys, collected annually from 2008-2010, monitored the impact of state-based financial incentives designed to promote rural and regional professional experience. Findings discussed in this article have implications for teacher educators and rural school leaders as they work in partnership with communities to support pre-service teachers on rural and regional practicum.

Cost-effectiveness of recruitment methods in a population-based epidemiological study: the Melbourne Visual Impairment Project

The cost-effectiveness of five recruitment methods was evaluated to determine the best method of encouraging eligible persons to participate in the Melbourne Visual Impairment Project (a population-based epidemiological study). The evaluation was divided into two phases. Phase 1 included one of two types of initial contact, by direct personal contact or by telephone. Phase 2 involved recruiting residents after an attempt had been made by either the telephone or the doorstep approach, and included a second attempt by a field interviewer, subsequent attempts by senior field staff, and finally, financial incentives. The cost-effectiveness of each method was determined by dividing the approach's cost by the effectiveness ratio. We identified 269 eligible households with 356 eligible residents. An 89 per cent response rate was achieved at the examination centre, comprising 61 per cent from Phase 1 and 28 per cent from Phase 2. Although both recruitment methods in Phase 1 were equally cost-effective, there was a significant difference in the effectiveness of each method in actually recruiting residents. The doorstep method was more costly per attender but was far more effective at 76 per cent recruitment than the telephone method at 47 per cent (P < 0.001). We have demonstrated a practical two-stage approach (the doorstep method in Phase 1 and follow-up strategies in Phase 2) to population-based recruitment involving the middle to elderly age group that should be relevant to many epidemiological studies.

Private protected areas in Australia: current status and future directions

Despite the recognised importance of private land for biodiversity conservation, there has been little research into systems of private protected areas at a country-wide level. Here I look at definitions, legislation, ownership, management approaches and effectiveness, distribution and incentives provided to private protected areas in Australia. The term 'private protected areas', although increasingly used, still suffers from a lack of a clear and concise definition in Australia. Australian states and territories have legislation enabling the application of conservation covenants over private land; covenants being the primary mechanism to secure conservation intent on the title of the land in perpetuity. If considering all 'in perpetuity' conservation covenants under a dedicated program to be private protected areas and land owned by non-government organisations and managed for the purpose of biodiversity conservation, there were approximately 5,000 terrestrial properties that could be considered private protected areas in Australia covering 8,913,000 ha as at September 2013. This comprises almost 4,900 conservation covenants covering over 4,450,000 ha and approximately 140 properties owned by private land trusts covering approximately 4,594,120 ha. Most conservation covenanting programs now seek to complement the comprehensiveness, adequacy and representativeness of the public reserve system, either stating so explicitly or by aiming to protect the highest priority ecosystems on private land. There are a range of incentives offered for private land conservation and requirements of owners of private protected areas to report on their activities vary in Australia. However, there are a number of key policy challenges that need to be addressed if private protected areas are to achieve their full potential in Australia, including managing broad-scale ecosystem processes, protection and tenure reform, improved financial incentives, and access to emerging ecosystem service markets.

Attitudinal and behavioural approaches to improving waste management on construction projects in Australia: Benefits and limitations

This research aims to understand the attitudes and behaviours of stakeholders towards waste management and consequently identify ways of improving waste management practices in construction projects. Semi-structured interviews were conducted. The findings reveal that most of the decisions in construction projects are based on their financial returns unless there is a special requirement to comply with Green Star or any other sustainable building rating system. Even though there is a trend towards environment-friendly construction, contractors are favourable towards methods involving financial incentives. Results also indicate that private developers are more price-driven compared with government clients. Findings reveal the necessity of enforcing legislation to improve waste management practices until such practices become culturally embedded in organizations across the supply chain. Similarly, end users' motivation towards waste management was also identified as a key to encouraging stakeholders of construction projects and improving their attitudes and behaviours towards waste management practices.

Implementation of China's new policies on organ procurement: An important but challenging step forward

In the last decade, health authorities in China have made a series of policy announcements concerning organ procurement programs and changes in practice have been intermittently reported (1). The international community of transplant professionals has followed these reports closely, preoccupied with one fundamental issue: the procurement of organs from executed prisoners, a practice that for many years has provided the majority of organs transplanted in China. Sharif et al. describe this practice as “ethically indefensible” (2), an evaluation that reflects the position embraced by the international community for more than two decades (3-5). Sharif et al. express concern that whilst some transplant programs in China have ceased using organs from executed prisoners, others continue to do so, and that all organs procured from the deceased may be allocated through a collective pool as part of the new China Organ Transplant Response System, effectively “laundering” organs obtained from prisoners. They also note that one of the new strategies to encourage deceased donation of organs among the Chinese public has involved financial incentives for donor families, another practice that has been strongly critiqued by the international professional community and global health authorities (6,7).

In China and in the United States, proponents of organ procurement from executed prisoners have argued that prisoners should not be denied the option to donate organs after their death if they so choose, as this may provide them or their families solace and an opportunity for moral, spiritual or social redemption (8,9). However, the predominant argument in favour of the practice appears to be essentially pragmatic: prisoners condemned to death represent an additional pool of potential “donors” with organs that will otherwise “go to waste” (10). In contrast, international professional societies and the World Health Organization among others have argued that the practice not only violates the core principles of medical ethics but also thereby undermines efforts to establish a sufficient supply of deceased donor organs. In this commentary, we reaffirm the ethics policy of The Transplantation Society (TTS) concerning organ procurement from executed prisoners (4), and briefly discuss the implications of this policy for international professional engagement with China at this time of significant evolution of Chinese organ procurement programs.

Living and deceased organ donation should be financially neutral acts

The supply of organs—particularly kidneys—donated by living and deceased donors falls short of the number of patients added annually to transplant waiting lists in the United States. To remedy this problem, a number of prominent physicians, ethicists, economists and others have mounted a campaign to suspend the prohibitions in the National Organ Transplant Act of 1984 (NOTA) on the buying and selling of organs. The argument that providing financial benefits would incentivize enough people to part with a kidney (or a portion of a liver) to clear the waiting lists is flawed. This commentary marshals arguments against the claim that the shortage of donor organs would best be overcome by providing financial incentives for donation. We can increase the number of organs available for transplantation by removing all financial disincentives that deter unpaid living or deceased kidney donation. These disincentives include a range of burdens, such as the costs of travel and lodging for medical evaluation and surgery, lost wages, and the expense of dependent care during the period of organ removal and recuperation. Organ donation should remain an act that is financially neutral for donors, neither imposing financial burdens nor enriching them monetarily.

The Doha model of organ donation and transplantation: thinking beyond citizenship

This paper reviews the policy and practice of organ donation and transplantation in Qatar that has developed since January 2011. The important features of the Doha Model (the ‘Model’) are explored, including: (i) all legal residents of Qatar have an equal right to access deceased donor organs and transplantation regardless of their citizenship status; (ii) no prioritisation in organ allocation is given to Qatari citizens; (iii) a multilingual and multicultural education and promotional program about donation has been implemented to engage the diverse national communities resident within Qatar; (iv) financial incentives or fungible rewards for living or deceased donation are prohibited. The ethical framework of this policy will be examined in the light of the national self-sufficiency paradigm, which advocates reciprocity and solidarity among resident populations seeking to meet all needs for transplantation equitably. We review some preliminary evidence of the impact of the Model with respect to engagement of a highly diverse multinational population in a donation and transplantation program, and argue that the Model may inform policy and practice in other countries, particularly those with non-citizen resident populations.