HEALTH STATUS - HEALTH SERVICE RESOURCES - ECONOSOCIOCULTURAL DEVELOPMENT: IMPLICATIONS FOR HEALTH CARE POLICY IN AFRICA

Rational health services planning requires an examination of the effects of various factors on the health status of a population within a given set of socioeconomic circumstances. The commonly accepted explanations for improved health in the less developed countries (LDCs) are: Health Service Resources available to a population, Environmental and Life conditions, and the Econosociocultural Characteristics of the population.^ In the context of the low economic base from which many LDCs initiate development activities, a strong imperative exists for identifying in which of these major areas public health policy would be most effective in terms of improving health. A new conceptual model is proposed that would be used for future policy analyses to assess what changes in health status of populations in LDCs can be expected as direct functions of increased health service resources, and of improved environmental and econosociocultural conditions.^ While direct policy analysis is ill-advised at this time due to data inadequacy, the model is illustrated using data presently available for twenty-five relatively homogeneous Sub-Sahara African countries. Within the limitations of available data, study findings indicate that while econosociocultural conditions were the most important explanatory factors of the three major independent variables in 1970, health service resources became the most important in 1975. Study findings are inconclusive at this time with regards to the relative contributions of physicians and medical assistants in explaining variances in mortality in these countries.^ Because of the deficient nature of available data, study findings should be interpreted very cautiously. Tests of statistical significance of study findings were by-passed because of their situational technical inappropriateness. This study is significant in being the first of its kind and scope to focus on the Sub-Sahara African region of the World Health Organization, using the Wroclaw Taxonomic Method in conjunction with a stepwise regression technique. It is desirable, therefore, to examine the observed magnitude and directional consistency of all hypothesized relationships, even if evidence is inconclusive. ^

HEALTH CARE COST INCREASES IN METROPOLITAN AREAS

The research project is an extension of the economic theory to the health care field and health care research projects evaluating the influence of demand and supply variables upon medical care inflation. The research tests a model linking the demographic and socioeconomic characteristics of the population, its community case mix, and technology, the prices of goods and services other than medical care, the way its medical services are delivered and the health care resources available to its population to different utilization patterns which, consequently, lead to variations in health care prices among metropolitan areas. The research considers the relationship of changes in community characteristics and resources and medical care inflation.^ The rapidly increasing costs of medical care have been of great concern to the general public, medical profession, and political bodies. Research and analysis of the main factors responsible for the rate of increase of medical care prices is necessary in order to devise appropriate solutions to cope with the problem. An understanding of the community characteristics and resources-medical care costs relationships in the metropolitan areas potentially offers guidance in individual plan and national policy development.^ The research considers 145 factors measuring community milieu (demographic, social, educational, economic, illness level, prices of goods and services other than medical care, hospital supply, physicians resources and techological factors). Through bivariate correlation analysis, the number of variables was reduced to a set of 1 to 4 variables for each cost equation. Two approaches were identified to track inflation in the health care industry. One approach measures costs of production which accounts for price and volume increases. The other approach measures price increases. One general and four specific measures were developed to represent each of the major approaches. The general measure considers the increase on medical care prices as a whole and the specific measures deal with hospital costs and physician's fees. The relationships among changes in community characteristics and resources and health care inflation were analyzed using bivariate correlation and regression analysis methods. It has been concluded that changes in community characteristics and resources are predictive of hospital costs and physician's fees inflation, but are not predictive of increases in medical care prices. These findings provide guidance in the formulation of public policy which could alter the trend of medical care inflation and in the allocation of limited Federal funds.^

THE EVALUATION OF PUBLIC HEALTH COMPONENTS OF INTERNATIONAL DISASTER RELIEF OPERATIONS: INDOCHINESE REFUGEES IN THAILAND, 1979-1982

Refugee populations suffer poor health status and yet the activities of refugee relief agencies in the public health sector have not been subjected previously to comprehensive evaluation. The purpose of this study was to examine the effectiveness and cost of the major public health service inputs of the international relief operation for Indochinese refugees in Thailand coordinated by the United Nations High Commissioner for Refugees (UNHCR). The investigator collected data from surveillance reports and agency records pertaining to 11 old refugee camps administered by the Government of Thailand Ministry of Interior (MOI) since an earlier refugee influx, and five new Khmer holding centers administered directly by UNHCR, from November, 1979, to March, 1982.^ Generous international funding permitted UNHCR to maintain a higher level of public health service inputs than refugees usually enjoyed in their countries of origin or than Thais around them enjoyed. Annual per capita expenditure for public health inputs averaged approximately US$151. Indochinese refugees in Thailand, for the most part, had access to adequate general food rations, to supplementary feeding programs, and to preventive health measures, and enjoyed high-quality medical services. Old refugee camps administered by MOI consistently received public health inputs of lower quantity and quality compared with new UNHCR-administered holding centers, despite comparable per capita expenditure after both types of camps had stabilized (static phase).^ Mortality and morbidity rates among new Khmer refugees were catastrophic during the emergency and transition phases of camp development. Health status in the refugee population during the static phase, however, was similar to, or better than, health status in the refugees' countries of origin or the Thai communities surrounding the camps. During the static phase, mortality and morbidity generally remained stable at roughly the same low levels in both types of camps.^ Furthermore, the results of multiple regression analyses demonstrated that combined public health inputs accounted for from one to 23 per cent of the variation in refugee mortality and morbidity. The direction of associations between some public health inputs and specific health outcome variables demonstrated no clear pattern. ^

Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Shifting the focus: Addressing breast cancer disparities at the health care organization level

The purpose of this study was to understand the scope of breast cancer disparities within the Texas Medical Center. The goal was to increase the awareness of breast cancer disparities at the health care organization level, and to foster the development of organizational interventions to reduce breast cancer disparities. The study seeks to answer the following questions: 1. Are hospitals in the Texas Medical Center implementing interventions to reduce breast cancer disparities? 2. What are their interventions for reducing the effects of non clinical factors on breast cancer treatment disparities? 3. What are their measures for monitoring, continuously improving, and evaluating the success of their interventions? ^ This research project was designed as a mixed methods case study. Quantitative breast cancer data for the years 2000-2009 was obtained from the Texas Cancer Registry (TCR). Qualitative data collection and analysis was done by conducting a total of 20 semi-structured interviews of administrators, physicians and nurses at five hospitals (A, B, C, D and E) in the Texas Medical Center (TMC). For quantitative analysis, the study was limited to early stage breast cancer patients: local and regional. The dependent variable was receipt of standard treatment: Surgery (Yes/No), BCS vs Mastectomy, Chemotherapy (Yes/No) and Radiation after BCS (Yes/No). The main independent variable was race: non-Hispanic White (NHW) , non-Hispanic Black (NHB), and Hispanic. Other covariates included age at diagnosis, diagnosis date, percent poverty, grade, stage, and regional nodes. Multivariate logistic regression was used to test the adjusted association between receipt of standard care and race. Qualitative data was analyzed with the Atlas.ti7 software (ATLAS.ti GmbH, Berlin). ^ Though there were significant differences by race for all dependent variables when the data was analyzed as a single group of all hospitals; at the level of the individual hospitals the results were not consistent by race/ethnicity across all dependent variables for hospitals A, B, and E. There were no racial differences in adjusted analysis for receipt of chemotherapy for the individual hospitals of interest in this study. For hospitals C and D, no racial disparities in treatment was observed in adjusted multivariable analysis. All organizations in this study were aware of the body of research which shows that there are disparities in breast cancer outcomes for patient population groups. However, qualitative data analysis found that there were differences in interest among hospitals in addressing breast cancer disparities in their patient population groups. Some organizations were actively implementing directed measures to reduce the breast cancer disparity gap in outcomes for patients, and others were not. Despite the differences in levels of interest, quantitative data analysis showed that organizations in the Texas Medical Center were making progress in reducing the burden of breast cancer disparities in the patient populations being served.^