Diabetes as a tracer condition in international benchmarking of health systems

OBJECTIVE - To assess the performance of health systems using diabetes as a tracer condition. RESEARCH DESIGN AND METHODS - We generated a measure of case-fatality among young people with diabetes Using the mortalily-to-incidence ratio (M/I ratio) for 29 industrialized countries using published data on diabetes incidence and mortality. Standardized incidence rates for ages 0-14 years were extracted from the World Health Organization DiaMond Study for the period 1990-1994; data on death from diabetes for ages 0-39 years were obtained from the World Health Organization Mortality database and converted into age-standardized death rates for the period 1994-1998, using the European standard population. RESULTS - The MA ratio varied > 10-fold. These relative differences appear similar to those observed in cohort studies of mortality among young people with type I diabetes in five countries. A sensitivity analysis showed that using plausible assumptions about potential overestimation of diabetes as a cause of death and underestimation of incidence rates in the U.S. yields an M/I ratio that would still be twice as high as in the U.K. or Canada. CONCLUSIONS - The M/I ratio for diabetes provides a means of differentiating countries on quality of care for people with diabetes. It is solely an indicator of potential problems, a basis for Stimulating more detailed assessments of whether such problems exist, and what can be done to address them.

Advanced Asia's health systems in comparison

There is growing interest in comparing patterns of social and health service development in advanced Asian economies. Most publications concentrate broadly on a range of core social services such as education, housing, social security and health care. In terms of those solely focused on health, most discuss arrangements in specific countries and territories. Some take a comparative approach, but are focused on presentation and discussion of expenditure, resourcing and service utilization data. This article extends the comparative analysis of advanced Asian health systems, considering the cases of Japan, South Korea, Taiwan, Hong Kong and Singapore. The article provides basic background information, and delves into common concerns among the world's health systems today including primary care organization, rationing and cost containment, service quality, and system integration. Conclusions include that problems exist in 'classifying' the five diverse systems; that the systems face common pressures; and that there are considerable opportunities to enhance primary care, service quality and system integration. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Using patient knowledge for better health systems

Purpose – This paper describes a “work in progress” research project being carried out with a public health care provider in the UK, a large NHS hospital Trust. Enhanced engagement with patients is one of the Trust’s core principles, but it is recognised that much more needs to be done to achieve this, and that ICT systems may be able to provide some support. The project is intended to find ways to better capture and evaluate the “voice of the patient” in order to lead to improvements in health care quality, safety and effectiveness. Design/methodology/approach – We propose to investigate the use of a patient-orientated knowledge management system (KMS) in managing knowledge about and from patients. The study is a mixed methods (quantitative and qualitative) investigation based on traditional action research, intended to answer the following three research questions: (1) How can a KMS be used as a mechanism to capture and evaluate patient experiences to provoke patient service change (2) How can the KMS assist in providing a mechanism for systematising patient engagement? (3) How can patient feedback be used to stimulate improvements in care, quality and safety? Originality/value –This methodology aims to involve patients at all phases of the study from its initial design onwards, thus leading to an understanding of the issues associated with using a KMS to manage knowledge about and for patients that is driven by the patients themselves. Practical implications – The outcomes of the project for the collaborating hospital will be firstly, a system for capturing and evaluating knowledge about and from patients, and then as a consequence, improved outcomes for both the patients and the service provider. More generally, it will produce a set of guidelines for managing patient knowledge in an NHS hospital that have been tested in one case example.

The Barriers to the Integration of the Uterine Balloon Tamponade into South Africa and Ghana's Health Systems for the Management of Postpartum Hemorrhage

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.

Secure and Privacy-aware Data Collection and Processing in Mobile Health Systems

Healthcare systems have assimilated information and communication technologies in order to improve the quality of healthcare and patient's experience at reduced costs. The increasing digitalization of people's health information raises however new threats regarding information security and privacy. Accidental or deliberate data breaches of health data may lead to societal pressures, embarrassment and discrimination. Information security and privacy are paramount to achieve high quality healthcare services, and further, to not harm individuals when providing care. With that in mind, we give special attention to the category of Mobile Health (mHealth) systems. That is, the use of mobile devices (e.g., mobile phones, sensors, PDAs) to support medical and public health. Such systems, have been particularly successful in developing countries, taking advantage of the flourishing mobile market and the need to expand the coverage of primary healthcare programs. Many mHealth initiatives, however, fail to address security and privacy issues. This, coupled with the lack of specific legislation for privacy and data protection in these countries, increases the risk of harm to individuals. The overall objective of this thesis is to enhance knowledge regarding the design of security and privacy technologies for mHealth systems. In particular, we deal with mHealth Data Collection Systems (MDCSs), which consists of mobile devices for collecting and reporting health-related data, replacing paper-based approaches for health surveys and surveillance. This thesis consists of publications contributing to mHealth security and privacy in various ways: with a comprehensive literature review about mHealth in Brazil; with the design of a security framework for MDCSs (SecourHealth); with the design of a MDCS (GeoHealth); with the design of Privacy Impact Assessment template for MDCSs; and with the study of ontology-based obfuscation and anonymisation functions for health data.

Multi-Principal Agency and the Compliance with Professional Guidelines in Health Systems: Economic and Regulatory Perspectives

Amid the trend of rising health expenditure in developed economies, changing the healthcare delivery models is an important point of action for service regulators to contain this trend. Such a change is mostly induced by either financial incentives or regulatory tools issued by the regulators and targeting service providers and patients. This creates a tripartite interaction between service regulators, professionals, and patients that manifests a multi-principal agent relationship, in which professionals are agents to two principals: regulators and patients. This thesis is concerned with such a multi-principal agent relationship in healthcare and attempts to investigate the determinants of the (non-)compliance to regulatory tools in light of this tripartite relationship. In addition, the thesis provides insights into the different institutional, economic, and regulatory settings, which govern the multi-principal agent relationship in healthcare in different countries. Furthermore, the thesis provides and empirically tests a conceptual framework of the possible determinants of (non-)compliance by physicians to regulatory tools issued by the regulator. The main findings of the thesis are first, in a multi-principal agent setting, the utilization of financial incentives to align the objectives of professionals and the regulator is important but not the only solution. This finding is based on the heterogeneity in the financial incentives provided to professionals in different health markets, which does not provide a one-size-fits-all model of financial incentives to influence clinical decisions. Second, soft law tools as clinical practice guidelines (CPGs) are important tools to mitigate the problems of the multi-principal agent setting in health markets as they reduce information asymmetries while preserving the autonomy of professionals. Third, CPGs are complex and heterogeneous and so are the determinants of (non-)compliance to them. Fourth, CPGs work but under conditions. Factors such as intra-professional competition between service providers or practitioners might lead to non-compliance to CPGs – if CPGs are likely to reduce the professional’s utility. Finally, different degrees of soft law mandate have different effects on providers’ compliance. Generally, the stronger the mandate, the stronger the compliance, however, even with a strong mandate, drivers such as intra-professional competition and co-management of patients by different professionals affected the (non-)compliance.

Economic crisis and counter-reform of universal health care systems: Spanish case

The economic crisis that has been affecting Europe in the 21st century has modified social protection systems in the countries that adopted, in the 20th century, universal health care system models, such as Spain. This communication presents some recent transformations, which were caused by changes in Spanish law. Those changes relate to the access to health care services, mainly in regards to the provision of care to foreigners, to financial contribution from users for health care services, and to pharmaceutical assistance. In crisis situations, reforms are observed to follow a trend which restricts rights and deepens social inequalities.

HypatiaSalud. Institucional Repository for the Andalusian Public Health System, Spain

HypatiaSalud will be the freely accessible institutional repository for the Public Health System in Andalucía, Spain. Open access and new technologies have changed dramatically the environment in which research is being conducted and disseminated. Traditionally University has been the universal research provider, but at present time there are Government Organizations, as Public Health Systems, which are large-producers of research. Meanwhile most universities are running institutional repositories or have plans of setting up institutional repositories in the short-term, there are not many Government Organizations working on that direction. In this sense, HypatiaSalud represents an innovative initiative. Objectives: - Enhancing institutional efficiency, effectiveness and opportunities for knowledge exchange. -Expanding access and greater use of research findings to a much wider range of users increasing the visibility and reputation of Andalusian Public Health System. - Providing the foundation for effective gathering and long-term preservation of research output. Methodology. Phase I: Researching and learning from other institutional repositories. Phase II: Designing and planning the financial, organizational, legal and technical underlying issues. Phase III: Launching the service. Phase IV: Running the service. Outcomes. Bibliometrics: catalog of the research output of the Institution, in order to determine the conditions to include this scientific output in the Institutional Repository: direct deposit, deposit after a period of embargo, or closed access when publisher will not grant permission. Promote a mandate for the deposit of all peer-reviewed final drafts (postprints) for institutional record-keeping purposes. Access to that immediate postprint deposit in HypatiaSalud may be set immediately as ‘Open Access’ if copyright conditions allows; otherwise access can be set as ‘Closed Access’. International Standards application: HypatiaSalud will support OAI-PMH and DRIVER, to allow that central repositories could harvest its content or metadata. Development of human resources strategies in order to foster self-archiving through merit acknowledge and accreditation. Conclusions. It seems likely that setting up an Institutional Repository for the Public Health System in Andalucía would have substantial net benefits in the longer term for the Institution, despite the lag between the costs and realisation of benefits.

Health care management autonomy: Evidence from the Catalonian hospital sector in a decentralised Spain

The organisation of inpatient care provision has undergone significant reform in many southern European countries. Overall across Europe, public management is moving towards the introduction of more flexibility and autonomy . In this setting, the promotion of the further decentralisation of health care provision stands out as a key salient policy option in all countries that have hitherto had a traditionally centralised structure. Yet, the success of the underlying incentives that decentralised structures create relies on the institutional design at the organisational level, especially in respect of achieving efficiency and promoting policy innovation without harming the essential principle of equal access for equal need that grounds National Health Systems (NHS). This paper explores some of the specific organisational developments of decentralisation structures drawing from the Spanish experience, and particularly those in the Catalonia. This experience provides some evidence of the extent to which organisation decentralisation structures that expand levels of autonomy and flexibility lead to organisational innovation while promoting activity and efficiency. In addition to this pure managerial decentralisation process, Spain is of particular interest as a result of the specific regional NHS decentralisation that started in the early 1980 s and was completed in 2002 when all seventeen autonomous communities that make up the country had responsibility for health care services.Already there is some evidence to suggest that this process of decentralisation has been accompanied by a degree of policy innovation and informal regional cooperation. Indeed, the Spanish experience is relevant because both institutional changes took place, namely managerial decentralisation leading to higher flexibility and autonomy- alongside an increasing political decentralisation at the regional level. The coincidence of both processes could potentially explain why some organisation and policy innovation resulting from policy experimentation at the regional level might be an additional featureto take into account when examining the benefits of decentralisation.

Improving Transportation and Warehousing Efficiency with Simulation-Based Decision Support Systems

Transportation and warehousing are large and growing sectors in the society, and their efficiency is of high importance. Transportation also has a large share of global carbondioxide emissions, which are one the leading causes of anthropogenic climate warming. Various countries have agreed to decrease their carbon emissions according to the Kyoto protocol. Transportation is the only sector where emissions have steadily increased since the 1990s, which highlights the importance of transportation efficiency. The efficiency of transportation and warehousing can be improved with the help of simulations, but models alone are not sufficient. This research concentrates on the use of simulations in decision support systems. Three main simulation approaches are used in logistics: discrete-event simulation, systems dynamics, and agent-based modeling. However, individual simulation approaches have weaknesses of their own. Hybridization (combining two or more approaches) can improve the quality of the models, as it allows using a different method to overcome the weakness of one method. It is important to choose the correct approach (or a combination of approaches) when modeling transportation and warehousing issues. If an inappropriate method is chosen (this can occur if the modeler is proficient in only one approach or the model specification is not conducted thoroughly), the simulation model will have an inaccurate structure, which in turn will lead to misleading results. This issue can further escalate, as the decision-maker may assume that the presented simulation model gives the most useful results available, even though the whole model can be based on a poorly chosen structure. In this research it is argued that simulation- based decision support systems need to take various issues into account to make a functioning decision support system. The actual simulation model can be constructed using any (or multiple) approach, it can be combined with different optimization modules, and there needs to be a proper interface between the model and the user. These issues are presented in a framework, which simulation modelers can use when creating decision support systems. In order for decision-makers to fully benefit from the simulations, the user interface needs to clearly separate the model and the user, but at the same time, the user needs to be able to run the appropriate runs in order to analyze the problems correctly. This study recommends that simulation modelers should start to transfer their tacit knowledge to explicit knowledge. This would greatly benefit the whole simulation community and improve the quality of simulation-based decision support systems as well. More studies should also be conducted by using hybrid models and integrating simulations with Graphical Information Systems.

Health benefits guarantees in Latin America: equity and quasi market restructuring at the beginning of the millennium

Includes bibliography

An assessment of the economic impact of climate change on the Agriculture, Health and Tourism sectors in Jamaica

This report analyses the agriculture, health and tourism sectors in Jamaica to assess the potential economic impacts of climate change on the sectors. The fundamental aim of this report is to assist with the development of strategies to deal with the potential impact of climate change on Jamaica. It also has the potential to provide essential input for identifying and preparing policies and strategies to help move the Region closer to solving problems associated with climate change and attaining individual and regional sustainable development goals. Some of the key anticipated manifestations of climate change for the Caribbean include elevated air and sea-surface temperatures, sea-level rise, possible changes in extreme events and a reduction in freshwater resources. The economic impact of climate change on the three sectors was estimated for the A2 and B2 IPCC scenarios until 2050. An evaluation of various adaptation strategies was also undertaken for each sector using standard evaluation techniques. The outcomes from investigating the agriculture sector indicate that for the sugar-cane subsector the harvests under both the A2 and B2 scenarios decrease at first and then increase as the mid-century mark is approached. With respect to the yam subsector the results indicate that the yield of yam will increase from 17.4 to 23.1 tonnes per hectare (33%) under the A2 scenario, and 18.4 to 23.9 (30%) tonnes per hectare under the B2 scenario over the period 2011 to 2050. Similar to the forecasts for yam, the results for escallion suggest that yields will continue to increase to mid-century. Adaptation in the sugar cane sub-sector could involve replanting and irrigation that appear to generate net benefits at the three selected discount rates for the A2 scenario, but only at a discount rate of 1% for the B2 scenario. For yam and escallion, investment in irrigation will earn significant net benefits for both the A2 and B2 scenarios at the three selected rates of discount. It is recommended that if adaptation strategies are part of a package of strategies for improving efficiency and hence enhancing competitiveness, then the yields of each crop can be raised sufficiently to warrant investment in adaptation to climate change. The analysis of the health sector demonstrates the potential for climate change to add a substantial burden to the future health systems in Jamaica, something that that will only compound the country’s vulnerability to other anticipated impacts of climate change. The results clearly show that the incidence of dengue fever will increase if climate change continues unabated, with more cases projected for the A2 scenario than the B2. The models predicted a decrease in the incidence of gastroenteritis and leptospirosis with climate change, indicating that Jamaica will benefit from climate change with a reduction in the number of cases of gastroenteritis and leptospirosis. Due to the long time horizon anticipated for climate change, Jamaica should start implementing adaptation strategies focused on the health sector by promoting an enabling environment, strengthening communities, strengthening the monitoring, surveillance and response systems and integrating adaptation into development plans and actions. Small-island developing states like Jamaica must be proactive in implementing adaptation strategies, which will reduce the risk of climate change. On the global stage the country must continue to agitate for the implementation of the mitigation strategies for developed countries as outlined in the Kyoto protocol. The results regarding the tourism sector suggest that the sector is likely to incur losses due to climate change, the most significant of which is under the A2 scenario. Climatic features, such as temperature and precipitation, will affect the demand for tourism in Jamaica. By 2050 the industry is expected to lose US$ 132.2 million and 106.1 million under the A2 and B2 scenarios, respectively. In addition to changes in the climatic suitability for tourism, climate change is also likely to have important supply-side effects from extreme events and acidification of the ocean. The expected loss from extreme events is projected to be approximately US$ 5.48 billion (A2) and US$ 4.71 billion (B2). Even more devastating is the effect of ocean acidification on the tourism sector. The analysis shows that US$ 7.95 billion (A2) and US$ 7.04 billion is expected to be lost by mid-century. The benefit-cost analysis indicates that most of the adaptation strategies are expected to produce negative net benefits, and it is highly likely that the cost burden would have to be carried by the state. The options that generated positive ratios were: redesigning and retrofitting all relevant tourism facilities, restoring corals and educating the public and developing rescue and evacuation plans. Given the relative importance of tourism to the macroeconomy one possible option is to seek assistance from multilateral funding agencies. It is recommended that the government first undertake a detailed analysis of the vulnerability of each sector and, in particular tourism, to climate change. Further, more realistic socio-economic scenarios should be developed so as to inform future benefit-cost analysis.

Evaluating the impact of vertical integration on health system peformance

Vertical integration is grounded in economic theory as a corporate strategy for reducing cost and enhancing efficiency. There were three purposes for this dissertation. The first was to describe and understand vertical integration theory. The review of the economic theory established vertical integration as a corporate cost reduction strategy in response to environmental, structural and performance dimensions of the market. The second purpose was to examine vertical integration in the context of the health care industry, which has greater complexity, higher instability, and more unstable demand than other industries, although many of the same dimensions of the market supported a vertical integration strategy. Evidence on the performance of health systems after integration revealed mixed results. Because the market continues to be turbulent, hybrid non-owned integration in the form of alliances have increased to over 40% of urban hospitals. The third purpose of the study was to examine the application of vertical integration in health care and evaluate the effects. The case studied was an alliance formed between a community hospital and a tertiary medical center to facilitate vertical integration of oncology services while maintaining effectiveness and preserving access. The economic benefits for 1934 patients were evaluated in the delivery system before and after integration with a more detailed economic analysis of breast, lung, colon/rectal, and non-malignant cases. A regression analysis confirmed the relationship between the independent variables of age, sex, location of services, race, stage of disease, and diagnosis, and the dependent variable, cost. The results of the basic regression model, as well as the regression with first-order interaction terms, were statistically significant. The study shows that vertical integration at an intermediate health care system level has economic benefits. If the pre-integration oncology group had been treated in the post-integration model, the expected cost savings from integration would be 31.5%. Quality indicators used were access to health care services and research treatment protocols, and access was preserved in the integrated model. Using survival as a direct quality outcome measure, the survival of lung cancer patients was statistically the same before and after integration. ^

Commodification of health care systems: The Catalan case

Commodification of the public healthcare system has been a growing process in recent decades, especially in universal healthcare systems and in high-income countries like Spain.  There are substantial differences in the healthcare systems of each autonomous region of Spain, among which Catalonia is characterized by having a mixed healthcare system with complex partnerships and interactions between the public and private healthcare sectors.  Using a narrative review approach, this article addresses various aspects of the Catalan healthcare system, characterizing the privatization and commodification of health processes in Catalonia from a historical perspective with particular attention to recent legislative changes and austerity measures.  The article approximates, the eventual effects that commodification and austerity measures will have on the health of the population and on the structure, accessibility, effectiveness, equity and quality of healthcare services.