Equity In Health Care Delivery Research Articles

Pharmacoeconomics and developing nations

The scarcity of resources within both industrialized and developing nations has catalyzed the adoption of more formalized approaches to support decisionmaking, particularly within healthcare. In many instances, however, the unique aspects present within developing countries may not permit the direct translation of pharmacoeconomic guidelines or recommendations from high-income economies. The purpose of this paper is to delineate the key attributes that differentiate pharmacoeconomics within developing nations, including the potential barriers to implementation and policy considerations involved. Through its approach to comprehensively assess costs and outcomes of technologies, pharmacoeconomic methodologies may help foster the optimal allocation of resources to improve the effectiveness, efficiency, and equity of healthcare delivery for societies worldwide.

Ensuring equity in healthcare delivery

AbstractOver the past 20 years, the development of health care services and the availability of health care coverage to the population have been accompanied by major gains in life expectancy. There remains, however, an issue in equity of access to health care services which may increase with the economic downturn. Evidence of health inequities can be found in health statistics all around Europe, where low income groups are less healthy and report more limitation to use of healthcare services than higher income groups. There is a strong commitment among researchers in health services to put health inequities on the political and research agendas. This is done by providing tools that assess the effect of new technologies on equity and by ensuring that dashboard indicators include measures of equity.

911 (Nueve Once): Spanish-Speaking Parents’ Perspectives on Prehospital Emergency Care for Children

Racial, ethnic and language-based disparities occur throughout the US health system. Pediatric prehospital emergency medical services are less likely to be used by Latinos. We identified perceptions of and barriers to prehospital pediatric emergency care (911) access among Spanish-speaking parents. A qualitative study involving six focus groups was conducted. Spanish-speaking parents participated with a bilingual moderator. Topics discussed included experiences, knowledge, beliefs, fears, barriers, and improvement strategies. All groups were audiotaped, transcribed, and reviewed for recurring themes. Forty-nine parents participated. Though parents believed 911 was available to all, many were uncertain how to use it, and what qualified as an emergency. Barriers included language discordance, fear of exposing immigration status, and fear of financial consequences. Parents strongly desired to learn more about 911 through classes, brochures, and media campaigns. Prehospital emergency care should be available to all children. Further quantitative studies may help solidify the identified barriers and uncover areas needing improvement within Emergency Medical Systems. Addressing barriers to 911 use in Spanish-speaking communities could improve the equity of health care delivery, while also decreasing the amount of non-emergency 911 use.

Measuring and decomposing socioeconomic inequality in healthcare delivery: A microsimulation approach with application to the Palestinian conflict-affected fragile setting

Socioeconomic-related inequalities in healthcare delivery have been extensively studied in developed countries, using standard linear models of decomposition. This paper seeks to assess equity in healthcare delivery in the particular context of the occupied Palestinian territory: the West Bank and the Gaza Strip, using a new method of decomposition based on microsimulations. Besides avoiding the 'unavoidable price' of linearity restriction that is imposed by the standard methods of decomposition, the microsimulation-based decomposition enables to circumvent the potentially contentious role of heterogeneity in behaviours and to better disentangle the various sources driving inequality in healthcare utilisation. Results suggest that the worse-off do have a disproportinately greater need for all levels of care. However with the exception of primary-level, utilisation of all levels of care appears to be significantly higher for the better-off. The microsimulation method has made it possible to identify the contributions of factors driving such pro-rich patterns. While much of the inequality in utilisation appears to be caused by the prevailing socioeconomic inequalities, detailed analysis attributes a non-trivial part (circa 30% of inequalities) to heterogeneity in healthcare-seeking behaviours across socioeconomic groups of the population. Several policy recommendations for improving equity in healthcare delivery in the occupied Palestinian territory are proposed.

Gender equity in treatment for cardiac heart disease in Portugal

Equity in health care delivery is one of the objectives of the Portuguese health care system. To date, research on this issue has mainly focused on income-related equity. This is the first study to shed light on gender equity, using a large data base that includes all patients admitted with cardiac heart disease at Portuguese NHS hospitals over the 2000-2006 period (259,519 discharges from 57 hospitals). In this paper we compare the use of catheterization and revascularization between men and women, controlling for age, comorbidities and hospital characteristics. Our findings show that women receive notably less catheterization and revascularization, with no significant change in this pattern over the 2000-2006 period. In addition, we observe that (i) gender differences disfavouring women are higher prior to detection of acute disease than after; (ii) women are significantly more likely to die during hospitalization despite equal treatment; (iii) gender differences against women are higher for non-elective admissions, and women are more often admitted through emergency units. These additional findings suggest that gender differences in detection, referral and treatment at early stages of the disease are likely to play a crucial role. They could possibly explain part of the higher gender differences before acute disease has been detected; they also lead women to be treated later, to be more frequently admitted through emergency units and to experience worse outcomes. However, alternative explanations cannot be discarded. The higher women's in-patient mortality may also signal gender differences in recovery from treatment, and the higher gap among emergency admissions could point to women's lower willingness to be treated. Further investigation should help to disentangle the precise role of each of these causal factors.

A focus on personal genomics.

Since the completion of the human reference genome [1], human geneticists have been using this ‘encyclopedia’ as a baseline for discovering the variation of the human genome at many levels, from SNPs to copy number variation, to complex structural variation. Such studies have largely focused on characterizing the genomic context of disease or disease susceptibility, initially through genome-wide association studies carried out on SNP arrays of ever-increasing density, with varying levels of success. More recently, by applying next-generation sequencing technology to re sequence and characterize entire human genomes, geneticists have set the stage for a revolution in personal genomics that will ultimately progress towards the reality of personalized medicine. Namely genomic data can be collected in a relatively straightforward manner within a matter of hours or days depending upon the technology, yielding a dataset that consists of an individual’s genotype (the unique combination of > 1 million single nucleotide variants as identified by a genotyping array) or of each of the approximately 6 billion nucleotide bases comprising the diploid genome. As a result, companies have been founded that offer ‘direct-to-consumer’ (DTC) genomic profiling and interpretation, individuals have had their own genomes sequenced [2–7] and mutated genes have been discovered in an unbiased fashion by sequencing complete cancer genomes [8,9]. Several scientific meetings have been organized around personal genomics, reflecting the dramatic increase in scientific efforts and interest in this area. The fields of human origins and pharmacogenetics, among others, have been re-energized by the emergence of the personal genome, with the anticipated results improving our understanding of migratory patterns and changing medical practice, respectively. The aforementioned advances in genomics technology and its applications have had unprece dented impacts on the fields of ethics and governance. The established framework of ethical, legal and social issues (ELSI) in genomics has been shaken to its foundations by something as simple as the emergence of personal genomics. Experts in the areas of ethics, social and political sciences, and governance, have been called to arms in order to restore the steady state that ELSI brought to genomics [10]. There are two tiers to the developments that result from technological progress, each of which confronts the ELSI disciplines with specific challenges. First, there are the aforementioned spectacular advances in sequencing. We have progressed from gene ana lysis to whole-genome scans in just half a decade. The availability of information regarding substantial parts of genomes, and even of full human genome sequences, has changed the way we look at such information – the building blocks of the human–organism are no longer hidden and it is becoming ever clearer that integrative personal genomics will enable rational and effective personalized medicine. Increasingly, individualized diagnostics and therapies require a rethinking in terms of justice and equity in healthcare delivery. In addition, new designs and strategies must be developed for both clinical trials and epidemiological studies. This means that substantial innovation in the field of research ethics will be needed. The integrative ‘omics’ sciences will not only change our concepts of health and disease, they will also redefine the interactions of the individual–human–organism and the environment. The second tier consists of the very sudden appearance in the market place of DTC genotyping services that, until recently, mainly provided certain types of selective genome scans. The established disciplines in the field of clinical genetics and in the ELSI area, as well as the various regulatory authorities, have been taken by surprise and, obviously, they are not able to

PUBLIC–PRIVATE PARTNERSHIPS FOR MATERNAL HEALTH IN AFRICA: CHALLENGES AND PROSPECTS

ABSTRACT The concept of public and private partnerships raises growing interest and hope from international development agencies, governments, and communities as an alternative strategy in social welfare delivery. Conceptualized as a strategy to build and capitalize on the tangible and intangible assets and resources endogenous to social organizations and communities, individually and collectively, this article embraces an asset-based approach to analyze the potency of such a framework in enhancing maternal health care delivery in developing countries such as Senegal and Mali. These countries face growing retrenchment of the state from social service delivery and scarcity of human and financial resources, which call for innovative approaches and sustainable solutions in addressing pervasive deficits in health service delivery. Drawing from empirical field research conducted in Senegal and Mali, this article examines the trend toward public–private partnerships and its gender impacts and critically analyzes the challenges and opportunities it offers conceptually and practically to address and improve equity in health care delivery, particularly safe motherhood and maternal health care delivery in developing countries.

Progressivity and horizontal equity in health care finance and delivery: What about Africa?

This paper applies concentration curves and indices, that have been previously used to analyze progressivity in health care finance and horizontal equity in health care delivery in developed countries, to a 1998–1999 household survey about health care expenditures and utilization carried out in four francophone West African capitals (Abidjan, Bamako, Conakry and Dakar). The paper also uses statistical inference for testing stochastic dominance relationship between curves, a technique already applied in the literature about equity in taxation, as the criterion for making rigorous inequality comparisons. In all four capitals, the results strongly suggest a regressive pattern of payments for health care, with lower income groups bearing an higher burden of health expenditures as a proportion of their income than do the higher income segments of the population. As soon as dominance between concentrations curves is statistically tested, results appear less conclusive, notably for the groups of population affected by severe morbidity, on the issue of horizontal inequity in health care delivery, which requires that persons with similar medical need be treated equally. Some recommendations are made for the use of equity measurements in access to care for future evaluations of the impact of health care reforms in Africa.

Opportunities and Challenges in Health Care Equity

Opportunities and Challenges in Health Care Equity

Using Q Methodology as a Strategy to Explore Cultural Opinions toward Health Care

The need for this study relates to the health disparity problem facing racially, ethnically, and socio-economically diverse people who may not seek or receive the necessary care to maintain their health. Describing the ways that underrepresented groups view wellness using Q methodology may lead to improvements in the quality and equity of health care delivery by increasing the cultural competency of providers. The Q sample was an expansion of one used previously (Sylvester, 2000). This study utilized Q methodology to identify attitudes about healthcare access of African Americans. Statements were added to broaden the range of opinions that might be expressed by other groups, including low-income and other ethnic groups. Of the 43 Oklahomans from various ethnic groups who sorted the 47-item Q set, three factors defined by 27 of the sorts were interpreted to be related to types of health care priorities. Care through Prevention view preventative health care most important, with an emphasis on a well-balanced lifestyle. Participants defining Care through Relationships place a particular focus upon developing strong relationships with caretakers. Participants defining Care for All recognize the need for all Oklahomans to have access to quality health care regardless of socioeconomic status. Implications for further research are discussed.

An Integrated Model for Community COPD Care

Chronic obstructive pulmonary disease (COPD) represents one of the main causes of morbidity and mortality in the western world. Acute exacerbations of COPD were a major cause of hospital admissions and emergency department attendances and represented a considerable economic burden on health resources in the Northern Sydney Area Health Service of Sydney, NSW. To redress deficits in access and equity in health care delivery and to align with best practice, the Area Health Service implemented a comprehensive, interagency, multidisciplinary model of care for chronic respiratory disease in the community setting. The BREATHE program provides nursing, physiotherapy, occupational therapy, clinical psychology, pharmacy and community care aid services in a client's home at a flexible level according to their acuity and complexity of health care needs. This program works in collaboration with primary care providers to provide specialty respiratory services not previously available. Since commencement of client intake in 2001, the program has observed reductions in health care utilisation and improvement in health outcomes.

Self-Reflection in Multicultural Training: Be Careful What You Ask For

Self-reflection in multicultural education is an important means to develop self-awareness and ultimately to change professional behavior in favor of more equitable health care to diverse populations. As conceptualized by scholars in the field of psychology, racial identity theory is critical to understanding and planning for the potentially wide range of predictable reactions to provocative activities, including those negative reactions that do not necessarily herald a flaw in programming. Careful consideration of racial identity developmental phases can also assist program planners to optimally meet the needs of individual physician trainees in their ongoing constructive professional and personal development, and in strategically mobilizing and having ready the type of institutional leadership that supports trainees' change processes. The authors focus on white physician trainees, the largest racial group of U.S. physicians and medical students. They first explain what they mean by the terms white and nonwhite. Racial identity theory is then applied, with true case examples, to explore such issues as where the self-proclaimed "color-blind" trainee fits into this theoretical schema, and how medical educators can best serve trainees who are resistant or indifferent to discussions of racism in medicine and equity in health care delivery. Ultimately, the authors' goal is to demonstrate that engendering genuine self-reflection can substantively improve the delivery of health care to the nation's diverse population. To help achieve that goal, they emphasize what to anticipate in effecting optimal trainee education and how to create an institutional climate supportive of individual change.

Health Status Adjustment and Income-Related Inequality in Health Care Delivery

The literature on equity in health care delivery agrees that adjusting for “medical need” is a necessary component in assessing whether the delivery of care is equitable, that is, whether it varies with ability to pay. To date, most studies measuring income-related inequality in the delivery of health care have employed crude measures of health status to adjust for medical need and have acknowledged this as a limitation. This study examines how using more complete health status measures affects estimates of income-related inequality for U.S. adults. The findings suggest that previous studies may understate the extent of pro-rich inequality.

Equity of health care in Australia

This paper examines the equity characteristics of health care financing and delivery in Australia and compares its performance with recent findings on systems in Europe and the United States. Vertical equity of finance is evaluated with income and payment concentration indices derived from published survey data on taxes and expenditure by income decile. Horizontal equity of health care delivery is assessed with standardized expenditure concentration coefficients for three measures of health status and four types of health services, derived from household survey data on health care utilization, health status, income and demographics. Health cover is available to the entire population. Results show the financing system is slightly progressive despite the fact that 30% of payment comes from private sources, which are regressive. The equity index compares favorably to many European countries and is much better than the U.S. which has a regressive financing system. The Australian system fares less well in terms of equity of health care delivery. Several features favor privately insured higher income persons in use of health care and this is reflected, for some health status measures and types of service, in inequity favoring the better off. This contrasts with inequity favoring the less well off in many European countries and the U.S. This analysis provides a benchmark for monitoring the equity of the Australian system and provides information on the equity of a mixed private and public financing system that covers the entire population. This is relevant to the U.S. which is moving in this direction by extending private cover to the uninsured and to European countries that are increasing private sector involvement in health care financing.