Health System Equity Research Articles

GOVERNMENT RESPONSIVENESS: THE EXTENT OF EQUITY IN HEALTH SERVICES IN TURKEY

Why is the objective of equity in the health sector significant? What is the relevance of equity, particularly in a medium-income country like Turkey, which has been ‘structurally adjusting’ for over three decades which planned to cut government expenditures by encouraging ‘cost-effectiveness’ and ‘efficiency’ in public services including the health sector? Has the health reform in Turkey since the early 1990s succeeded in ensuring its enhancement, despite an extensive discussion on equity? In this study, equity in the health sector in Turkey were analysed considering its basic dimensions including finance and provision. The Health Services Utilization Survey (HUS) conducted in 1992 was used us to show the extent of the problem of inequity in the health system in Turkey and the areas of intervention toward a more equitable health sector. This has been instrumental in understanding how and why equity can be relevant in enhancing the responsiveness of the government to the health care needs of the population. The analysis revealed that the inequity problem in Turkey was mainly from the inequalities in health insurance coverage and the geographical distribution of the health care resources. To overcome structural problems as well as inefficiencies in the health system, government started a series of reforms under the Health Transformation Project in 2003. The unification of the existing health insurance schemes and introduction of the universal health insurance to the whole population in 2008 was a prominent change in the health system. Our framework of analysis in this study can provide a basis for evaluating the effect of recent changes to the equity in health system in Turkey. A similar analysis will enable whether there has been any improvement in the health system in reaching its equity objective.

Scorecards for health system performance assessment: The New Zealand example

Objective To develop a national scorecard for assessing health system performance derived from routine data. Methods We drew upon national and international data to develop benchmarks for health system performance, then applied basic ratio scores to compare New Zealand performances to the benchmark. 64 indicators were included in four assessment categories: healthy lives, quality, access, and efficiency. In a fifth category, 27 of these indicators were used to score health system equity. Indicator scores in each category were then averaged to give a health system score out of 100. Results New Zealand's health system achieved an overall score of 71 out of 100. The system scored relatively well on quality and efficiency, but poorly on equity despite considerable government investment in reducing inequalities. Conclusions The scorecard offers a useful method for combining a range of data to give an overall picture of health system performance, highlighting strengths, weaknesses and areas for improvement. This initial study provides a baseline for assessing New Zealand's performance over time and, where data permit, a template for other countries to follow.

Monitoring Gender Equity in Health Using Gender-Sensitive Indicators: A Cross-National Study

As gender is known to be a major determinant of health, monitoring gender equity in health systems remains a vital public health priority. Focusing on a low-income (Peru), middle-income (Colombia), and high-income (Canada) country in the Americas, this study aimed to (1) identify and select gender-sensitive health indicators and (2) assess the feasibility of measuring and comparing gender-sensitive health indicators among countries. Gender-sensitive health indicators were selected by a multidisciplinary group of experts from each country. The most recent gender-sensitive health measures corresponding to selected indicators were identified through electronic databases (CINAHL, PsycINFO, MEDLINE, Embase, LILACS, LIPECS, Latindex, and BIREME) and expert consultation. Data from population-based studies were analyzed when indicator information was unavailable from reports. Twelve of the 17 selected gender-sensitive health indicators were feasible to measure in at least two countries, and 9 of these were comparable among all countries. Indicators that were available were not stratified or adjusted by age, education, marital status, or wealth. The largest between-country difference was maternal mortality, and the largest gender inequity was mortality from homicides. This study shows that gender inequities in health exist in all countries, regardless of income level. Economic development seemed to confer advantages in the availability of such indicators; however, this finding was not consistent and needs to be further explored. Future initiatives should include identifying health system factors and risk factors associated with disparities as well as assessing the cost-effectiveness of including the routine monitoring of gender inequities in health.

The policy agenda for prevention and control of non-communicable diseases

Robust national policies and strategies developed and owned by national authorities are fundamental for prevention and control of non-communicable diseases (NCDs). The objective of this paper is to address broad policy areas in respect of NCD prevention and control from a public health perspective, with a special focus on low- and middle-income countries (LMIC). The paper is a condensation of current World Health Organization (WHO) reports in this field supported by relevant literature obtained from a Medline search for the period 2000-2010. There is a strong evidence base that underpins the NCD policy agenda. National NCD policies can make a substantive impact on public health in LMIC if they are geared to addressing primary prevention and equity of health systems. National NCD policies help to catalyse, and coherently integrate regulatory, legislative and multisectoral actions across health and other health relevant sectors. Such multisectoral action is integral for creation of conducive environments to support healthy behaviours. There is agreement that health systems need reconfiguration to ensure equitable access to essential NCD interventions. Although the magnitude of the NCD burden is high and is growing in LMIC, international development assistance to address the burden remains negligible. How exactly gaps in formulation, and implementation of NCD policies can be addressed when there are severe limitations in human resource capacity, financial resources and competing health priorities in LMIC is not clear. Context-specific research is required to address implementation gaps in NCD policy, as policy development and implementation are driven by political realities and cultural specificities. Research is also needed to develop innovative approaches for revenue generation for prevention and control of NCDs.

La descentralización de los servicios de salud: de la teoría a la práctica

The current promoters of the decentralization of health services affirm that its implementation will improve the quality, equity and efficiency of health systems and at the same time will increase users' satisfaction. Additionally, those who advocate decentralization believe that it will facilitate community participation in health decisionmaking, and as a result it will strengthen the democratic process. In this study we discuss first the lack of consensus regarding the meaning of decentralization and the difficulties of measuring the degree of decentralization of a health system. We also identify the actors who have formulated the above hypotheses, examine the reasons behind its formulation, and analyze if the outcome of the decentralization of the Latin American health services confirm the hypotheses.

A Roundtable of Innovative Leaders in Medical Education

In 2008, the Global Health Education Consortium (GHEC) created the Training for Health Equity Network (THEnet), bringing together schools in different parts of the world that share a core mission: to recruit students from, and produce physicians for, underserved communities. In determining the competencies such physicians will need, these schools also share an approach to medical education that looks beyond the traditional curriculum and seeks the involvement of communities and other stakeholders. Their input helps define the knowledge, skills, and attitudes around which new curriculum is built, and helps guide the selection of educational methodologies, taking into account context and resource constraints. The nascent THEnet now has a nucleus of eight member schools, each dedicated to fulfilling a strong social accountability mandate. The network is designed to assist them by providing a collaborative platform conducive to experimentation; dialogue; and creation and sharing of tools, experiences and evidence. It will also support systematic outcome evaluations, innovation, and joint research to strengthen the knowledge base on successful strategies for increasing the number and quality of doctors in neglected communities. By bringing these schools together, developing synergy among them and publishing their results, THEnet hopes to more broadly promote the transformation of medical education and medical practice into more socially accountable endeavors that improve health system equity and performance. Leaders from six of these innovative medical schools spoke with the Guest Editors of this issue of MEDICC Review, a conversation we bring you below. They are: Dr Juan Carrizo, Rector of the Latin American Medical School (ELAM), Cuba; Dr Fortunato L. Cristobal, founding Dean of the School of Medicine at Ateneo de Zamboanga University (AZU), the Philippines; Dr Pedro D�az, member of the National Academic Coordinating Committee of the National Training Program for Comprehensive Community Physicians (NTPCCP), Venezuela; Dr Richard Murray, Dean and Head of the School of Medicine and Dentistry, James Cook University (JCU), Australia; Dr Roger Strasser, founding Dean of Northern Ontario School of Medicine (NOSM), Canada; and Dr Paul Worley, Dean of Flinders University School of Medicine (FUSM), Australia. Erratum Neusy, AJ, Palsdottir, B. A Roundtable of Innovative Leaders in Medical Education. MEDICC Review. 2008;10(4):20-24. The correct website for the Ateneo de Zamboanga University School of Medicine in the Philippines is: http://som.adzu.edu.ph.

Choice of public or private health insurance: learning from the experience of Germany and the Netherlands

Several European countries have considered introducing choice of public or private health insurance - usually by allowing people to ‘opt out’ of the statutory scheme - under the assumption that enhancing consumer choice and stimulating competition between insurers will be beneficial. This article examines the impact of opting out on equity and efficiency in European health systems. Focusing on Germany and the Netherlands - the only European countries where this type of choice has been available to significant population groups for a prolonged period (from 1970 to the present day in Germany, and from 1941 to 1986 in the Netherlands) - the analysis suggests that current policy debates may overstate the potential benefits of opting out. Due to market failures in health insurance and differences in the regulatory frameworks governing public and private insurers, choice of public or private coverage creates strong incentives for private insurers to select risks and leads to risk segmentation, thereby breaching equity in funding health care, heightening the financial risk borne by public insurers and lowering incentives for private insurers to operate efficiently. Measures can be taken to correct these negative effects, but some forms of regulation may be politically and technically difficult to implement.

Health services utilization: a systematic review of related factors

Health services utilization is determined by various factors. In order to study which factors are most important in different countries, a systematic review was conducted from 1970 to 1999. The mean number of visits, proportion of persons who see a doctor, and proportion that concentrate the most visits were similar. Children, childbearing-age women, and the elderly use health care services the most. Lower-income and less educated groups are also significantly associated with more frequent utilization. Increased health needs mediate more frequent utilization by these groups. However, the poorest groups may not receive adequate care, depending on the respective type of health system. Health need is one of the most important determinants in utilization, and if a health system's equity is to be analyzed, one must consider patterns of utilization among social groups in relation to the level of greatest need. Regularly visiting the same physician, a characteristic of accessibility to health care services, can determine more adequate utilization. This factor can reduce differences in health care among groups. The authors conclude by proposing a hierarchy of related factors.

Managing the health care market in developing countries: prospects and problems.

There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries.