Changes In Health Sector Research Articles

Changes in Health Care Workers’ Economic Outcomes Following Medicaid Expansion

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known. To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations. Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys. Time-varying state-level adoption of Medicaid expansion. Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits. The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion. Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Health system performance in Iran: a systematic analysis for the Global Burden of Disease Study 2019

SummaryBackgroundBetter evaluation of existing health programmes, appropriate policy making against emerging health threats, and reducing inequalities in Iran rely on a comprehensive national and subnational breakdown of the burden of diseases, injuries, and risk factors.MethodsIn this systematic analysis, we present the national and subnational estimates of the burden of disease in Iran using the Global Burden of Disease Study 2019. We report trends in demographics, all-cause and cause-specific mortality, as well as years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) caused by major diseases and risk factors. A multi-intervention segmented-regression model was used to explore the overall impact of health sector changes and sanctions. For this analysis, we used a variety of sources and reports, including vital registration, census, and survey data to provide estimates of mortality and morbidity at the national and subnational level in Iran.FindingsIran, which had 84·3 million inhabitants in 2019, had a life expectancy of 79·6 years (95% uncertainty interval 79·2–79·9) in female individuals and 76·1 (75·6–76·5) in male individuals, an increase compared with 1990. The number of DALYs remained stable and reached 19·8 million (17·3–22·6) in 2019, of which 78·1% were caused by non-communicable diseases (NCDs) compared with 43·0% in 1990. During the study period, age-standardised DALY rates and YLL rates decreased considerably; however, YLDs remained nearly constant. The share of age-standardised YLDs contributing to the DALY rate steadily increased to 44·5% by 2019. With regard to the DALY rates of different provinces, inequalities were decreasing. From 1990 to 2019, although the number of DALYs attributed to all risk factors decreased by 16·8%, deaths attributable to all risk factors substantially grew by 43·8%. The regression results revealed a significant negative association between sanctions and health status.InterpretationThe Iranian health-care system is encountering NCDs as its new challenge, which necessitates a coordinated multisectoral approach. Although the Iranian health-care system has been successful to some extent in controlling mortality, it has overlooked the burden of morbidity and need for rehabilitation. We did not capture alleviation of the burden of diseases in Iran following the 2004 and 2014 health sector reforms; however, the sanctions were associated with deaths of Iranians caused by NCDs.FundingBill & Melinda Gates Foundation.

How the Institutional and Policy Context Shapes the Establishment of Nurse Practitioner Roles and Practice in New Zealand's Primary Health Care Sector.

The implementation of the nurse practitioner (NP) workforce in primary health care (PHC) in New Zealand has been slow, despite ongoing concerns over persisting health inequalities and a crisis in the primary care physician workforce. This article, as part of a wider institutional ethnography, draws on the experiences of one NP and two NP candidates, as they struggle to establish and deliver PHC services in areas of high need, rural, and Indigenous Māori communities in New Zealand. Using information gathered initially by interview, we develop an analysis of how the institutional and policy context is shaping their experiences and limiting opportunities for the informants to provide meaningful comprehensive PHC. Their work (time and effort), with various health organizations, was halted with little rationale, and seemingly contrary to New Zealand's strategic direction for PHC stipulated in the Primary Health Care Strategy 2001. The tension between the extant biomedical model, known as primary care, and the broader principles of PHC was evident. Our analysis explored how the perpetuation of the neoliberal health policy environment through a "hands-off" approach from central government and district health boards resulted in a highly fragmented and complex health sector. Ongoing policy and sector perseverance to support privately owned physician-led general practice; a competitive contractual environment; and significant structural health sector changes, all restricted the establishment of NP services. Instead, commitment across the health sector is needed to ensure implementation of the NP workforce as autonomous mainstream providers of comprehensive PHC services.

Examining national and district-level trends in neonatal health in Peru through an equity lens: a success story driven by political will and societal advocacy.

BackgroundPeru has impressively reduced its neonatal mortality rate (NMR). We aimed, for the period 2000–2013, to: (a) describe national and district NMR variations over time; (b) assess NMR trends by wealth quintile and place of residence; (c) describe evolution of mortality causes; (d) assess completeness of registered mortality; (e) assess coverage and equity of NMR-related interventions; and (f) explore underlying driving factors.MethodsWe compared national NMR time trends from different sources. To describe NMR trends by wealth quintiles, place of residence and districts, we pooled data on births and deaths by calendar year for neonates born to women interviewed in multiple surveys. We disaggregated coverage of NMR-related interventions by wealth quintiles and place of residence. To identify success factors, we ran regression analyses and combined desk reviews with qualitative interviews and group discussions.ResultsNMR fell by 51 % from 2000 to 2013, second only to Brazil in Latin America. Reduction was higher in rural and poorest segments (52 and 58 %). District NMR change varied by source. Regarding cause-specific NMRs, prematurity decreased from 7.0 to 3.2 per 1,000 live births, intra-partum related events from 2.9 to 1.2, congenital abnormalities from 2.4 to 1.8, sepsis from 1.9 to 0.8, pneumonia from 0.9 to 0.4, and other conditions from 1.2 to 0.7. Under-registration of neonatal deaths decreased recently, more in districts with higher development index and lower rural population. Coverage of family planning, antenatal care and skilled birth attendance increased more in rural areas and in the poorest quintile. Regressions did not show consistent associations between mortality and predictors. During the study period social determinants improved substantially, and dramatic out-of-health-sector and health-sector changes occurred. Rural areas and the poorest quintile experienced greater NMR reduction. This progress was driven, within a context of economic growth and poverty reduction, by a combination of strong societal advocacy and political will, which translated into pro-poor implementation of evidence-based interventions with a rights-based approach.ConclusionsAlthough progress in Peru for reducing NMR has been remarkable, future challenges include closing remaining gaps for urban and rural populations and improving newborn health with qualified staff and intermediate- and intensive-level health facilities.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3405-2) contains supplementary material, which is available to authorized users.

Health sector changes must reach further

Change management is relevant for healthcare leaders at all levels. This article offers a literature review and pulls from the author's own experience to emphasize the importance of transformative, sustainable change. Leaders are reminded that change comes from within, draws from all levels of the organization, and must be pervasive throughout a project.

Dialectics of Rational Change Management in Regional Social Systems

In the article, the attention is paid to a role of service-producing industries rendering social services, promoting human development in the modern state. Theoretical positions of scientists considering meaning of the social benefits and need of active state support of the social sphere are generalized. The condition of the Russian service-producing industries is considered, the comparative analysis of indicators of their activity with indicators of service-producing industries of other countries is carried out. In view of indicators of the efficiency ratings of national education systems, world countries on the health systems efficiency, world countries on the level of social development of 2014, the author’s conceptual approach is offered; it considers interconditionality and interdependence of level of public financing of the social sphere and dynamics of a contribution of service-producing industries to the human capital development providing a gain of gross domestic product of the country. Need of innovative changes in socio-economic systems of service-producing industries for the efficiency increase of their activity, taking into account the received results — first of all in health care is proved. Theoretical approaches to management of changes in socio-economic systems are investigated. On the basis of the conducted research, the created theoretical basis of the level increase of change management in open socioeconomic systems for the purpose of the theoretical and methodological approaches to development to change management in relation to health sector, the optimization model of management of health care organizations ranging controlled and uncontrollable changes is offered. The use possibilities of management optimization by ranging controlled and uncontrollable changes in health sector of different management levels are confirmed by the high rates of performance efficiency on micro-, meso- and macrolevel in industry on the example of implementation of national project Health and innovative organizational transformations promoting the return to work of the patients of working-age participating in development of gross domestic product across Yekaterinburg.

The EHMA Agora for seeking new paradigms

At the opening session of the EHMA Annual Conference in Lahti, Finland, participants engaged in The Largo Simulation that instantly demonstrated the actuality of the conference theme: ‘Managing Radical Change in Health’. The simulation moderator, Laurie McMahon, confronted his audience with two major policy issues that will dominate health sector change in EU member states during the next decade. First, he raised the question about how to protect and improve health status in the face of the current recession. Public health research on previous economic crises has uncovered a broad range of negative effects on health and well-being, especially for lower socio-economic status groups. Second, he clarified the far-reaching consequences of the economic crisis on public funding of health services. EU governments are facing an unprecedented need to cut back budget deficits and national debts. As a consequence, they are looking for savings on health services expenditure on a scale not seen before. For example, the Dutch government is exploring opportunities to cut parts of its health sector budget by 20%. Other EU governments are looking for interventions of the same kind of magnitude. The health sector is used to financial pressure. Cost containment policies emerged in all Western countries during the 1980s, in reaction to a heavy economic recession and the extraordinary growth of health services expenditure in preceding years. Governments and health authorities filled a policy toolkit with instruments for restricting health service entitlements, refining need assessment procedures, slowing down capital investment, extending the range of co-payments, intervening in drugs price setting, tightening up macro budget control, and so on. During the last two decades the use of this toolkit intensified, as the growth rate of the publicly funded health sector tended to exceed domestic economic growth rate over and again. Under this pressure provider organizations have developed a broad repertoire of cost-saving routines to deal with recurrent budget cuts. These range from simply stopping waste, standardizing working procedures, and tightening financial control to measures to reduce labour costs and smarter procurement and utilization of buildings and equipment. Horizontal and vertical integration became a popular managerial option to pursue economies of scale and scope, as did substitution of cost-intensive clinical services for cheaper day treatment and ambulatory care. Efficiency became the buzz word that guided strategic actions on both the national and organizational levels. However, the present combination of growing health-care needs and macro-economic pressure on the sector requires strategic responses that go far beyond the conventional political and managerial routines of dealing with tight financial resources. This rapidly became visible for the participants participating in The Largo Simulation. First, everybody started to tackle the health and financial issues with solutions that had demonstrated their effectiveness in the past. Then, participants began to realize that the current socio-economic conditions imply a trend break with that past that strongly limits the effectiveness of those solutions. They recognized that out-of-the-box thinking is required to develop innovative responses to the changed circumstances. So they started to question the taken-for-granted values, principles and routines behind the organization and funding of health services. They questioned existing relationships between public funding, private payments, and charity. They explored the potential of radical patient self-management, of health operations management principles, and of redefining professional roles. They discussed the promises of prevention programmes and replacing organizational control by trust. Potential limits to equal access were reviewed as the development of unconventional sets of health insurance entitlements. They also considered the gains of replacing organizational hierarchy by

Leadership, institution building and pay-back of health systems research in Mexico

BackgroundHealth systems research is being increasingly called upon to support scaling up of disease control interventions and to support rapid health sector change. Yet research capacity building and pay-back take years or even decades to be demonstrated, while leadership and institution building are critical for their success. The case of Mexico can be illustrative for middle income countries and emerging economies striving to build health research systems.MethodsHistorical reflection suggests the relationship between health sector reforms and economic crisis, on the one hand, and research capacity building and payback, on the other. Mexico's post-revolutionary background and its three health sector reforms are analyzed to identify the emphases given to health systems research.ResultsThe first wave of health reform in the 1940s emphasized clinical and epidemiological research. Health systems research was not encouraged in a context of rapid economic development and an authoritarian regime. In contrast, health systems research was given a privileged place with the second wave of health reforms in the 1980s, which addressed health system coordination, decentralization and the universal right to health in a context of a deep economic crisis. The third wave of health reforms between 2003 and 2006 was based on the health system models proposed through research in the 90s. The credibility gained by research institutions was critical to ensure government uptake. Research influence can be traced through the role it played in defining a problem, in designing innovative insurance mechanisms and in establishing evaluation frameworks. It is argued that the Ministry of Health's budget increase of 56% between 2003 and 2006 and the reductions in inequity are pay-back to research investments since the 1980s.

Public Health Capacity Building in Southeastern Europe

The political disintegration of former Yugoslavia inaugurated in 1991 resulted in the decentralization of health systems in the federation's successor nation-states. Efforts by the Open Society Institute improved public health planning and management needs consequent to health sector changes. Beginning in Croatia in 2001, the Institute developed ongoing collaborations between Andrija Stampar School of Public Health and the US Centers for Disease Control and Prevention. In 2003 and 2004, it expanded its project to include the republics of Macedonia and of Serbia and Montenegro.

European Health Systems Reforms: Looking Backward to See Forward?

In this article we outline the different schools of new institutionalism and a few other selected political science theories. Moreover, we relate the insights offered by a series of analyses of health sector change in a large number of European countries over the past twenty to thirty years to these theoretical frameworks. Our main conclusion is that it is unlikely that a single explanatory theory will ever be able to account for all of the health sector developments in any one country, let alone across many countries with diverse cultures, histories, institutions, and interest groups. Consequently, a real understanding of health sector change will require a recognition that different theoretical approaches will be more (or less) appropriate in some circumstances than in others.

The English National Health Service: 1979-2005

This article aims to assess the development of the English National Health Service (NHS) over the period 1979--2005, against the original, and often repeated, core objectives of the system: that it be universal in offering coverage to all members of the population in times of health care need; that it be comprehensive in its provision of health care services; and that it be (largely) free at the point of use. Comprehensiveness is open to interpretation, and may depend upon the wealth of the nation. Universality and (largely) free care at the point of use, which lend themselves to the principle of equal access for equal need, are more concrete, and it is not difficult to ascertain if they have been substantially and/or systematically violated. The article details briefly the developments in resource allocation, provider payment mechanisms, incentives and accountability, and notes that much of the emphasis on health sector change since the mid 1980s has been placed upon improving supply side efficiency and reducing waiting lists/times. Improving NHS efficiency, and indeed related aspirations associated with choice and health outcomes, can be perceived as 'secondary' objectives, in that they should not serve to undermine the core objectives of the system, assuming that the security offered by having an accessible, universal health care system is considered worthy of protection. The overall conclusion is that the NHS has performed quite well against its core objectives to date, although it is possible that the current preoccupation with choice and health outcomes will lead us down a different policy path in the future.

The impact on officials of public sector restructuring

There has been limited examination of the impact of public sector restructuring on affected officials. This paper seeks to address the imbalance. It discusses the case of the New Zealand Health Funding Authority, dissolved and merged in 2000 as part of a major health sector restructuring programme. The paper overviews literature on change management and organisational mergers, outlines New Zealand's succession of public health sector changes through the 1990s, and details the procedures involved in the health funding authority restructuring. The impact on senior health funding authority staff and their impressions of the change process studied through the lens of a survey conducted in August 2000 are discussed, along with lessons from the New Zealand case.

One Country, Four Systems: Comparing Changing Health Policies in New Zealand

There is a growing literature in comparative health policy that analyzes the experiences of different countries. This article draws upon the comparative tradition, but has an intra-country focus. It considers the case of New Zealand, which has had four different public health sector structures in a decade, with fundamental changes enacted following general elections in 1990, 1996 and 1999. New Zealand's structures have included a system of locally based area health boards responsible for both funding and services delivery in their regions; a competitive, profit-oriented market system with separate agencies purchasing and providing health-care services; a centralized system with one corporate agency planning for population needs and purchasing services from a range of providers; and a system in which planning and purchasing is devolved to district boards. In tandem with the constant restructurings, a variety of policy and service innovations have emerged in areas such as the organization of primary-care physicians, indigenous Maori health care, pharmaceutical purchasing and the prioritization of services and patients. First, the article reviews the field of comparative health policy studies. Next, it outlines New Zealand's four health sector structures. Lastly, the article discusses the performance, implications and lessons of New Zealand's successive health sector changes.

Reproductive health and health sector reform in developing countries: establishing a framework for dialogue.

It is not clear how policy-making in the field of reproductive health relates to changes associated with programmes for the reform of the health sector in developing countries. There has been little communication between these two areas, yet policy on reproductive health has to be implemented in the context of structural change. This paper examines factors that limit dialogue between the two areas and proposes the following framework for encouraging it: the identification of policy groups and the development of bases for collaborative links between them; the introduction of a common understanding around relevant policy contexts; reaching agreement on compatible aims relating to reproductive health and health sector change; developing causal links between policy content in reproductive health and health sector change as a basis for evidence-based policy-making; and strengthening policy-making structures, systems, skills, and values.

Health insurance as a catalyst to change in former communist countries?

A large number of former communist countries are currently undergoing a process of insurance led health sector change. Social health insurance is seen as a major source of income for the health sector, as a way of inducing fundamental restructuring of provision and of encouraging greater individual awareness of the costs (and benefits) of publicly financed health care. Attempts to introduce social medical insurance have generally been criticized by western policy analysts yet continue to have much appeal in each country. Obtaining additional revenue for the health sector is clearly a major motivation for these reforms. Yet available evidence suggests that many countries will obtain revenue that is lower and less stable than envisaged. For some countries other reasons for insurance may be as important. One of the most important is the greater autonomy given to the national Ministry of Health and local health departments over expenditure allocation. Recent experience of voluntary insurance in Turkmenistan confirms many of the fears about the feasibility and impact of social health insurance. Yet establishing an attractive but contained benefits package has been popular with the population and offers a potentially useful approach for inducing more fundamental reform.

The impact of political transformation in South Africa on public/private mix policy debates

South Africa has experienced the change from apartheid and free market policies towards a nonracial democracy addressing poverty and inequalities. Changes also occurred in the private/public health care sector between 1980 and 1991. An explanation for the health sector changes and the nature of the policy debate are discussed. Private sources of health care have expanded while real per capita public expenditure on health declined private sources of finance increased and the distribution of health care providers changed. Private sector was directly affected by the pressures to reduce public spending s a means of adjustment to the debt crisis the influential ideology of monetarism and privatization lobbies and the growth in numbers of Black workers with health insurance. The proportion of private sector providers increased from 47.2% in 1979 to 57.8% in 1987 while public sector providers declined from 53% to 42%. In 1987 96% of private sector doctors were self-employed. Public health services deteriorated concomitantly with decreased expenditures and the shift of skilled personnel to the private sector. Rural health services declined due to the lack of supply of overseas doctors; this supply was affected by the anti-apartheid boycotts the perception of South Africa as politically unsafe the exits out of the country of military conscripts due to compulsory service requirements and higher incomes for doctors overseas. Currently the private sector has over 50% of the doctors serving over 20% of the population. The transitional end of the post-apartheid era will expose the greater demand for public spending while economic uncertainties prevail. A strong health lobby of medical professional groups and business interests has promoted privatization of health care as an economic advantage and an opportunity to deracialize the issues of access to health care. The opposition has rallied behind a demand for a National Health Service while the Black trade unions have helped to secure the fee for service in the private sector. After 1990 the policy debates changed markedly. Nationalizing private health care would increase the states liability to pay for care which opens up discussion of how the private sector can be regulated in order to control the more destructive impacts.