Health Policy Objectives Research Articles

Decline with a capital D: long‐term changes in general practice consultation patterns across Australia

To determine changes in the pattern of use of standard general practice consultations, and the degree to which any changes are offset by the use of special Medicare Benefits Schedule (MBS) items. Population-based retrospective analysis of age- and sex-standardised Medicare claims data (1994-2009) on the utilisation of general practice standard consultations (Levels A, B, C and D) alone and in combination with health assessments and care plans and other special MBS items. Utilisation rates of Level C and D (long) consultations increased consistently from 1994 to 2004, but by 2009 a considerable decline had occurred. A reverse of this pattern was observed for Level A (short) consultations. When utilisation rates for special items and long consultations were combined, the combined utilisation rate followed an upward trend until 2007, but also declined in 2008 and 2009. The decline in the use of Level C and D consultations in recent years has been dramatic and accompanied by an increase in use of Level A consultations. While the use of special items has offset the decline in long consultations, this compensating effect has weakened in the past 2 years. This pattern is at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management. Given the current situation, the recently introduced Medicare reforms (May 2010), including changes to Levels B, C and D consultation item descriptors, may not be sufficient to change consultation patterns.

Pay scheme preferences and health policy objectives

This paper studies the preferences among healthcare workers towards pay schemes involving different levels of risk. It identifies which pay scheme individuals would prefer for themselves, and which they think is best in furthering health policy objectives. The paper adds, methodologically, a way of defining pay schemes that include different levels of risk. A questionnaire was mailed to a random sample of 1111 dentists. Respondents provided information about their current and preferred pay schemes, and indicated which pay scheme, in their opinion, would best further overall health policy objectives. A total of 504 dentists (45%) returned the questionnaire, and there was no indication of systematic non-response bias. All public dentists had a current pay scheme based on a fixed salary and the majority of individuals preferred a pay scheme with more income risk. Their preferred pay schemes coincided with the ones believed to further stabilise healthcare personnel. The predominant current pay scheme among private dentists was based solely on individual output, and the majority of respondents preferred this pay scheme. In addition, their preferred pay schemes coincided with the ones believed to further efficiency objectives. Both public and private dentists believed that pay schemes, furthering efficiency objectives, had to include more performance-related pay than the ones believed to further stability and quality objectives.

An Integrated Alcohol Control Policy: What, Why and How?

In response to the calls for more integrated governmental actions across different policy sectors, this paper discusses what an integrated alcohol control policy is; why alcohol control policies should be integrated; and how alcohol control policy integration can be accomplished. The theoretical discussion is illustrated by empirical examples from Finnish and Swedish alcohol control policies in their encounter with the European Union (EU). The central argument of this paper is that the impact of international free trade commitments on domestic alcohol control policies will depend on how this policy sector is organized and operates. Alcohol control policies are more likely to survive in an international free trade context if they are tightly integrated around the health and social policy objectives they are intended to promote and protect. This implies that attempts should be made to achieve a clearer divorce of public health and social policy objectives related to alcohol on the one hand, and from trade and commercial objectives on the other.

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

The aim of this study was to assess trends in treatment intensity in outpatient child and adolescent mental health services (CAMHS) in Norway from 1998 to 2006. During this period, Norway experienced substantial growth in available CAMHS resources. In 2002 hospital ownership was recentralized and health enterprises were established. A nonexperimental, interrupted time-series design was used to estimate trends adjusted for patient case mix and CAMHS size. From a panel of 37 CAMHS units, two subsamples were extracted. These patients (N=94,173) were aged 0-17 years and had participated in at least one treatment session with a therapist (direct consultation) during the year of observation. Direct and indirect consultations (appointments with cooperating services) were separately analyzed with multilevel regression analyses. Patient-level factors were the main sources of variation in number of consultations. CAMHS unit size was positively associated with direct consultations in both subsamples. A trend of increased direct consultations was observed in one subsample. Comparing the period 2002-2006 with 1998-2001 revealed a positive shift in treatment intensity for both consultation types in both subsamples. Trends and shifts differed between patient groups according to the main reason for referral and gender. The main health policy objective during the study period was increased access to mental health treatment. Both access and treatment intensity increased. The study was inconclusive about whether incentives related to CAMHS performance measurement caused treatment intensity to increase, specifically after the 2002 hospital ownership reform.

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

Breast cancer screening among Asian immigrant women in Canada

Objective: The objective of this study was to examine the pattern of breast cancer screening among Asian immigrant women aged 50–69 years and compare it with corresponding non-immigrant women in Canada. Methods: Data from the Canadian Community Health Survey cycle 2.1 (2003) were utilized. Self-reported screening histories were used as outcome variables: socioeconomic status and medical histories were used as predictive variables. Analyses were weighted to represent the target population. Multivariate logistic regression analyses were performed to compare the screening pattern among Asian immigrant women and corresponding non-immigrant Canadians. Results: In total, 508 Asian immigrant women were included in this study. The results suggest that 71% and 60% of Asian immigrant women reported ever having had and recent mammogram use, respectively, while the corresponding figures for non-immigrant women were 89% and 72%. The observed differences were statistically significant and could not be explained by confounding factors. The ability to speak one of the two official languages is an important barrier to mammography screening among Asian immigrant women. Conclusion: The findings show lower rates of mammography screening among Asian immigrant women in Canada. If breast screening is to remain a health policy objective in Canada, targeted efforts to increase the recruitment of Asian immigrant women need to be developed or strengthened.

"It depends on what you mean": a qualitative study of Swedish health professionals' views on health and health promotion.

BackgroundThe role of health services must be re-oriented towards health promotion to more effectively contribute to population health. One of the objectives of the Swedish public health policy is that health promotion and disease prevention should be an integral part of the health care system and an important component of all care and treatment. However, the uncertainty about what the concepts of health and health promotion mean poses a challenge for implementation. Depending on how these concepts are interpreted, the attitudes of health professionals toward health promoting practices will differ. Thus, a more in-depth understanding of health professionals' views can be a starting point for a discussion about the values and attitudes that influence the current health care system and about the barriers and possibilities for future development of a health promoting health service.MethodsSeven focus group discussions (n = 34) were carried out with health professionals, from different health care settings, to understand how they communicate about health and health promotion. The data were analyzed using qualitative content analysis.ResultsThe analysis of health professional's general understanding of the concept of health resulted in the category; a multi-facetted concept, whilst the category; a subjective assessment describes what health means to themselves. A third category; health is about life, the whole life. describes their understanding of health as an outcome of a multiplicity of contextually dependent determinants.The health professional's multiple ways of associating health promotion to disease prevention suggest a concept that is diffuse, elusive and difficult to apply in practice. Despite a shared view of health, the health professionals described their health promotion role very differently depending partly on how the concept of health promotion was interpreted. The analysis resulted in the development of three ideal types, labelled the demarcater, the integrater and the promoter describing different strategies for handling a health promotion role in practiceConclusionThe study suggests that different interpretations of what constitutes health promotion can lead to unnecessary misunderstandings and pose barriers to further development of a health promoting practice.

A Model of Patient Choice with Mid-Therapy Information

For many treatments, a patient's prognosis may be refined by conducting a mid-therapy assessment (MTA). When therapy lasts some time, an MTA predicts a patient's ultimate outcome based on early signs of response. The availability and timing of such assessments also serve as a mechanism by which policy makers can influence patients' treatment-initiation decisions. In this article, we examine how patients evaluate treatment options using MTAs of treatment effectiveness and discuss the policy implications of patient decision making in such contexts. To this end, we use indifference-curve analysis to characterize trade-offs between potential treatment success versus potential adverse effects in therapeutic situations where patients are encouraged to consider their own motivations for initiating treatment. Treatment initiation for chronic hepatitis C virus (HCV) infection is used for illustration, but the analysis can be easily adapted to a variety of clinical scenarios.Analysis shows that the existence of MTAs influences patients' initial treatment decisions by affecting the expectations of treatment success and adverse effects. Earlier MTAs have lower sensitivity and higher specificity, and the prior expectation of adverse effects is accordingly lower for two reasons. First, the lower chance for a false signal of treatment response and the higher chance for a false signal of no response make it more likely that the patient receives a signal leading to discontinuation. Second, if a signal to discontinue is received, fewer weeks of adverse effects have been endured before discontinuation occurs. Both factors make the expected burden of adverse effects lower when the MTA occurs earlier. Later MTAs have higher sensitivity and lower specificity, both of which serve to increase the probability of treatment completion, causing a higher prior likelihood of treatment success.These findings indicate that treatment demand may be increased by changing the timing of MTAs, depending on the information content of the alternative mid-therapy signals and the nature of patient preferences. In HCV infection and other diseases, clinical practice guidelines for conducting MTAs might be modified to better achieve public health or other policy objectives by studying the economics of patient choice.

Explicit incorporation of equity considerations into economic evaluation of public health interventions

Health equity is one of the main avowed objectives of public health policy across the world. Yet economic evaluations in public health (like those in health care more generally) continue to focus on maximizing health gain. Health equity considerations are rarely mentioned. Health economists rely on the quasi-egalitarian value judgment that 'a QALY is a QALY'--that is QALYs are equally weighted and the same health outcome is worth the same no matter how it is achieved or to whom it accrues. This value judgment is questionable in many important circumstances in public health. For example, policy-makers may place rather little value on health outcomes achieved by infringing individual liberties or by discriminating on the basis of age, sex, or race. Furthermore, there is evidence that a majority of the general public wish to give greater weight to health gains accruing to children, the severely ill, and, to a lesser extent, the socio-economically disadvantaged. This paper outlines four approaches to explicit incorporation of equity considerations into economic evaluation in public health: (i) review of background information on equity, (ii) health inequality impact assessment, (iii) analysis of the opportunity cost of equity, and (iv) equity weighting of health outcomes. The first three approaches can readily be applied using standard methods of health technology assessment, where suitable data are available; whereas approaches for generating equity weights remain experimental. The potential benefits of considering equity are likely to be largest in cases involving: (a) interventions that target disadvantaged individuals or communities and are also relatively cost-ineffective and (b) interventions to encourage lifestyle change, which may be relatively ineffective among 'hard-to-reach' disadvantaged groups and hence may require re-design to avoid increasing health inequalities.

General Practitioner Commissioning in the English National Health Service: Continuity, Change, and Future Challenges

General practitioner fundholding (GPFH) in the English National Health Service was abolished by the Blair administration in 1999 amid concerns that it was inequitable, helped to foster a "two-tier" health service, and incurred high transaction costs. In April 2005 in an apparent volte face, the Blair government reintroduced delegated budgets to individual GP practices under the banner of Practice Based Commissioning (PBC). As PBC bears many similarities to GPFH it is timely to take stock of evidence-based policy lessons from the earlier initiative in the NHS. Based on a review of the latest empirical evidence, the aim of this article is to help inform the development and implementation of PBC by identifying the policy lessons of GPFH. To do this the discussion focuses on three main areas: it (1) reviews key ideas and conceptual frameworks for understanding stability and change in health systems; (2) summarizes the origins and evolution of primary care commissioning in the NHS; and (3) examines the latest literature and empirical analysis on the impact of GPFH and assesses the success of GPFH in meeting a range of health policy objectives. The article concludes with an examination of the policy implications of the present review and a look forward at the emerging research agenda.

Farm subsidies and obesity in the United States: National evidence and international comparisons

Many commentators have claimed that farm subsidies have contributed significantly to the “obesity epidemic” by making fattening foods relatively cheap and abundant. But U.S. farm policies have generally small and mixed effects on farm commodity prices, which in turn have even smaller and still mixed effects on the relative prices of more- and less-fattening foods. Other factors have had much more influence on reducing the farm prices of food commodities and the consumer prices of food such that any effects of U.S. farm policies on U.S. obesity patterns must have been negligible. Moreover, while many arguments can be made for changing U.S. farm subsidies, even entirely eliminating the current programs could not be expected to have a significant influence on obesity rates. International evidence reinforces this finding. The countries that support their farmers most strongly tend to have relatively low obesity rates. In these countries the main support for farmers comes through trade barriers and higher consumer prices, which—like U.S. policies for sugar, dairy, orange juice, and beef—discourage consumption and reduce obesity. In contrast with agricultural subsidies, agricultural R&D has had a significant effect in the past on the relative price of food commodities and food, and has the potential to influence obesity patterns in the future, but R&D policy is a very blunt instrument for pursuing public health policy objectives.

Balancing health and industrial policy objectives in the pharmaceutical sector: Lessons from Australia

Policy-makers worldwide struggle to balance health with industrial policy objectives in the pharmaceutical sector. Tensions arise over pricing and reimbursement in particular. What health plans view as necessary to maintain equitable access to medicines, industry views as inimical to R&D and innovation. Australia has grappled with this issue for years, even incorporating the goal of "maintaining a responsible and viable medicines industry" into its National Medicines Policy. This case study was conducted via a narrative review that examined Australia's experiences balancing health and industrial policy objectives in the pharmaceutical sector. The review included electronic databases, grey literature and government publications for reports on relevant Australian policy published over the period 1985-2007. While pharmaceutical companies claim that Australia's pricing and reimbursement policies suppress drug prices and reduce profits, national policy audits indicate these claims are misguided. Australia appears to have secured relatively low prices for generics and "me-too drugs" while paying internationally competitive prices for "breakthrough" medicines. Simultaneously, Australia has focused efforts on local pharmaceutical investment through a variety of industry-targeted R&D incentive policies. Despite the fact that policy reviews suggest that Australia has achieved balance between health and industrial policy objectives, the country continues to face criticism from industry that its health goals harm innovation and R&D. Recent reforms raise the question whether Australia can sustain the apparent balance.

„...in erster Linie nur um das Wohl und Wehe der Zahnärzte“ – „Reichszahnärzteführer“ Ernst Stuck (1893–1974)

From the very beginning German dentists and their scientific and professional organizations were involved in the disastrous developments following the Nazi assumption of power of 1933. After purging and both organisational and ideological streamlining which had been comparatively rapidly accomplished in 1933/34 a development started which was characterized by extreme professional confrontation and lust for power in close entanglement with Nazi health policy objectives and deformation of scientific dentistry. A decisive role was assigned to the Reichszahnärzteführer Ernst Stuck (1893-1974) who was the highest representative of the dental profession throughout the Nazi Regime. However, up to the present his life and position has not been thoroughly researched. What is more, history of dentistry has been looking at his activities in a merely cursory and appeasing way. In fact, his function as Reichszahnärzteführer needs to be critically scrutinized and evaluated.

Health and security in foreign policy.

Introduction Historically, health has occupied the lower echelons of national priorities. Over the past decade, however, national policy-makers have increasingly recognized the deleterious impacts that health crises may have on national interests. As a result, particular health issues occasionally have been elevated within national agendas, especially if they have implications for foreign policy and/or they are perceived as threats to national security. Identifying a health issue as a foreign policy or security issue, or both, may lead to higher prioritization and more attention from top policy-makers, in turn, bringing greater political support and more funding. (1) While health professionals may welcome the higher profile and greater resources given to their issues, characterizing a health issue as a national priority (and particularly as a security issue) may change the understanding of a health threat, put relatively greater emphasis on the views of those outside the health community and potentially alter the approach to solving the problem. Consequently, care should be taken in deciding which health issues should be given priority on par with national security issues and included explicitly in national foreign policy. We support the assertion that [w]hile it is clear that health issues often intersect with security issues, not all health challenges represent security concerns. (2) Health issues that do not pose security threats should not be contextualized as such, since doing so may detract from overarching public health and foreign policy objectives. At the same time, however, we believe that efforts to address all types of health issues through foreign policy contribute to overall improvements in diplomatic relations, which may enhance the security of countries. Health in foreign policy Many health challenges, particularly infectious diseases, are widely recognized as global concerns that do not respect borders. As a result, countries often include in their foreign policies strategies on diseases that have the potential to threaten domestic interests. Public health challenges that are not concomitant security threats should be given consideration as foreign policy priorities on their own merits, without forcing them to be viewed through the prism of national security. One example of a health issue that is addressed through foreign policy but is not a security issue is poliomyelitis. The eradication of polio requires sustained financial commitments and coordinated international efforts. Such coordination has resulted from countries negotiating high-level political commitments under the auspices of the Group of Eight (G8) and other organizations that are not typically seen as health institutions. Despite polio's role as a major cause of disability (and consequent loss of productivity), donor commitment to the Polio Eradication Initiative is not rooted in a concern for its economic or security impact, but in the belief that eradication would be a major victory for public health and would achieve a global good. The impetus for the international effort against polio is not national security concerns but an altruistic desire to ameliorate human morbidity and mortality. Thus, it can be argued that polio eradication is a foreign policy issue for countries, but not a national security issue. Although characterizing a health issue as a foreign policy issue may provide greater visibility and greater funding, there is also a likelihood that programmes associated with such health priorities may be subject to enhanced political scrutiny. Additionally, identifying a particular health issue as a national (or international) priority inherently alters its importance relative to other public health issues. Since resources are generally limited and new funding is difficult to obtain, there is a great risk that the prioritized disease will draw resources away from other health programmes. …

The social shaping of childhood vaccination practice in rural and urban Gambia

Improving childhood vaccination coverage is a key health policy objective in Africa, and as availability increases, it will depend on addressing issues of demand and timely schedule completion. This paper explores vaccination demand in urban and rural areas of The Gambia as shaped by prevailing local vaccination cultures (comprising maternal knowledge and understandings, socio-cultural contexts and interactions with health providers). A survey of 1,600 mothers constructed on the basis of prior ethnography finds a high level of social demand for vaccination, based on lay theories of the general value of immunization in complementing traditional child protection practices. For most rural mothers, strong social networks encourage routine clinic attendance and vaccination 'default' arises only through day-to-day problems and contingencies. However, more pervasive patterns of schedule non-completion are found amongst poorer urban mothers, including recent immigrants, who experience social exclusion at infant welfare clinics. These findings point to the need for health education dialogue grounded in mothers' own understandings and for particular policy attention to improving the clinic experiences of vulnerable social groups in rapidly expanding urban areas.

Clinics, Communities, and Cost Recovery

Upon coming to power in 1994, South Africa’s first postapartheid government launched its ambitious Reconstruction and Development Programme with several major primary health care initiatives. Two years later, it adopted a macroeconomic policy that put neoliberal reforms ahead of redistributive goals. Based on ethnographic research in one urban health district, this article examines the consequences of this discordant national policy configuration as manifested in the micropolitics of four community clinics. The article examines contrasting experiences of desegregation in two formerly ‘White’ facilities, and contrasting community responses to two newly built township clinics. The article finds that, in general, South Africa’s neoliberal shift undermined its health policy objectives. However, in exceptional cases where strong nurse leadership combined with relatively uncontentious local class relations, some community clinics did succeed in becoming sites for the local pursuit of health and development goals.

Towards a wireless patient: Chronic illness, scarce care and technological innovation in the United Kingdom

‘Modernization’ is a key health policy objective in the UK. It extends across a range of public service delivery and organizational contexts, and also means there are radical changes in perspective on professional behaviour and practice. New information and communications technologies have been seen as one of the key mechanisms by which these changes can be engendered. In particular, massive investment in information technologies promises the rapid distribution and deployment of patient-centred information across internal organizational boundaries. While the National Health Service (NHS) sits on the edge of a £6billion investment in electronic patient records, other technologies find their status as innovative vehicles for professional behaviour change and service delivery in question. In this paper, we consider the ways that telemedicine and telehealthcare systems have been constructed first as a field of technological innovation, and more recently, as management solutions to problems around the distribution of health care. We use NHS responses to chronic illness as a medium for understanding these shifts. In particular, we draw attention to the shifting definitions of ‘innovation’ and to the ways that these shifts define a move away from notions of technological advance towards management control.

The Alcohol Policy Development Process: Policymakers Speak

We investigate the policymaking activities of members of the federal alcohol-policy community, including efforts to raise issues on the agenda, develop policy alternatives, and influence political decisions. Qualitative data (observations, attitudes, and activities in relation to alcohol policymaking dynamics) from 64 key-informant interviews inform this analysis of strategies and tactics. The paper draws on archival data, including interest-group newsletters and government documents. It describes the various perspectives from which Congress, federal agencies, industry groups (alcohol producers, national trade organizations, broadcasters, and advertisers), public health activist organizations, researchers, and journalists view the process of federal-level alcohol policymaking. While there are considerable differences in problem-framing strategies and paradigms, alcohol policymakers view the dynamics in ways consistent with political scientists' theories based on general health policy. Insights gained have the potential to improve understanding of public policymaking in the alcohol area and could help to advance public health policy objectives.

Community pharmacy in Ghana: enhancing the contribution to primary health care

It is widely believed that pharmacists could make a greater contribution to the provision of primary health care, especially in developing countries. Particular strengths of pharmacy services commonly cited include their accessibility within many communities and the opportunities for advising on the management of health problems. The potential for pharmacy to respond to health care needs and contribute to specific health policy objectives is receiving greater prominence both internationally and in individual countries. However, despite this widely acknowledged potential, developments have been limited. Pharmacy is concerned with promoting the safe and appropriate use of drugs. Drug use in developing countries has frequently been described as irrational. It is influenced by a wide range of factors, including health and drugs policy, the organization and provision of health care, the availability of objective information, and health beliefs and cultural perspectives regarding health and drug therapy. The practices of pharmacy retailers, which are conducted in the context of wider structures and processes of health care provision, have also been questioned. The aim of this paper is to consider possible directions for community pharmacy service development in Ghana. The paper draws on the literature relating to health care, drug use and pharmacy in Ghana to describe the background against which pharmacy services operate. In the context of current directions in pharmacy practice and policy, potential opportunities and barriers regarding the development of services are then addressed.

Cervical cancer mortality by neighbourhood income in urban Canada from 1971 to 1996.

The reduction of socioeconomic inequalities in health is an explicit objective of health policy in Canada, yet rates of death from cervical cancer are known to be higher among women of low socioeconomic status than among those of higher socioeconomic status. To evaluate progress toward the World Health Organization's goal of "Health for All," we examined whether income-related differentials in cervical cancer mortality diminished from 1971 to 1996. Death registration data for Canada's census metropolitan areas in 1971, 1986, 1991 and 1996 were assigned to census tracts through postal code, and the tracts were in turn assigned to income quintiles based on their proportion of the population below the Statistics Canada low-income cutoff values. We compared age-standardized death rates (using the 1966 world population standard) in the female population (excluding those in institutions) across the 5 income quintiles and calculated interquintile rate ratios (poorest over richest) and interquintile rate differences (poorest minus richest). From 1971 to 1996, the overall age-standardized cervical cancer death rate per 100 000 women (and 95% confidence interval) declined from 5.0 (4.5-5.6) to 1.9 (1.7-2.1), the interquintile rate ratio diminished from 2.7 (1.8-4.2) to 1.7 (1.1- 2.6), and the interquintile rate difference decreased from 4.6 (2.8- 6.4) to 1.1 (0.2-1.9). The income-related disparity in rates of death from cervical cancer as measured by rate ratios and rate differences diminished markedly in urban Canada from 1971 to 1996. Among the numerous factors that may have contributed to the decline (including decline in fertility and improvement in diet), one important factor was probably the implementation of effective screening programs.