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Biomedical subjects

Martin McKee

Publications and source records attributed to Martin McKee.

138 records · Page 8Linked to original sources
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Access to health care in a system transition: the case of Bulgaria.

OBJECTIVE: Throughout the 1990s, the Soviet-style model in central and eastern Europe that provided free health services has been subject to radical reforms. Socio-economic inequalities have also increased but there is little information on inequalities in health care utilization. This paper examines the pattern of illness behaviour in Bulgaria, seeking evidence of inequalities in access to services and eliciting users' pathways to care. DESIGN: Analysis drew on a representative population survey in Bulgaria (1997). The financial determinants of service use were tested in a multivariate model adjusted first for age, and then for age, marital status and self-reported health. In-depth interviews with users and providers addressed pathways to care, use of connections and other informal strategies to obtain care. RESULTS: As expected, rates of illness vary with income, with highest rates among the poor. After adjustment for illness, consultation rates are relatively equal across income levels, with the exception of worse-off women who tend to consult more. For first contact, there are few differences according to income, with the better off preferring secondary level. Pathways slightly differ, with women more often treated in primary care. Private sector utilization is low. Qualitative research reveals well-established strategies to obtain more advanced care, including use of connections, informal payments and use of emergency services. CONCLUSIONS: An apparent lack of inequalities in access to care conceals a more complex picture in which income and gender influence the pathways taken through the system.

Adult↗
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The human perspective on health care reform: coping with diabetes in Kyrgyzstan.

Health systems world wide are confronted by the challenge of rising levels of chronic diseases. Yet existing approaches to health system analysis often fail to capture the complexity of the responses required to address this challenge. In this paper we describe the results of a pilot study using a rapid appraisal technique to assess the performance of the health care system in Kyrgyzstan, a former Soviet central Asian republic. The study focuses on diabetes, a condition whose effective management requires a coordinated response involving many components of the health care system. The study sets out a conceptual framework in which the system is seen from the perspectives of users, health professionals and policy-makers. It sees the effective delivery of health care as dependent on appropriate investment in human, physical, intellectual and social resources. The study reveals important weaknesses in all of these areas, although it also notes that current policies, while constrained by the legacy of the past and by limited resources, are beginning to tackle them. This pilot study indicates that rapid appraisal, using a condition such as diabetes, where those affected can be easily identified, offers a means of gaining important insights into a health care system.

Adaptation, Psychological↗
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Informal payment for health care and the theory of 'INXIT'.

Informal payments are known to be widespread in the post-communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious, with the debate characterized by much polemic. This paper steps back from this debate to examine the theoretical basis for understanding the persistence of informal payments. The authors develop a cognitive behavioural model of informal payment, which draws on the theory of government failure and extends Hirschman's theory of 'exit, voice, loyalty', the behavioural responses to 'decline in firms, organizations and states'. It is argued that informal payment represents another possible behavioural reaction: 'inxit', which becomes important when the channels of exit and voice are blocked. The theory is applied to explain informal payments in Hungary, but can be shown to be relevant to other countries facing similar issues. The paper examines the proposed policies to tackle informal payments, and on the basis of the theory of 'inxit' it advocates that solutions should contain an appropriate balance between exit and voice to optimize the chances of maintaining a good standard of public services.

Delivery of Health Care↗
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INTERHEART.

Explore the source record for details and available documents.

Alcohol Drinking↗
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Pushing up smoking incidence: plans for a privatised tobacco industry in Moldova.

Moldova, one of the former Soviet republics and Europe's poorest country, has so far resisted pressure to privatise its tobacco industry. This paper examines the policies pursued by the transnational tobacco companies in Moldova in order to inform the ongoing debate about tobacco industry privatisation. We analysed relevant internal industry documents made public through litigation. The documents suggest that although a competitive tender for the state owned monopoly was later announced, British American Tobacco (BAT) and the German manufacturer Reemtsma each initially sought to secure a closed deal, with BAT accusing Reemtsma of underhand tactics. Imperial Tobacco, which now owns Reemstma, was unable to comment on these allegations as it only acquired Reemstma after the events in question. BAT sought to acquire a monopoly position, bolstered by excise rules developed by the company that would uniquely favour its products. Despite hoping to establish a monopoly, it planned intensive marketing, as if in a competitive market, aiming to target young urban dwellers, particularly opinion leaders. In so doing it predicted that smoking uptake would increase, especially among women. The documents also suggest that BAT was aware of the sensitive nature of its plans to cull the processing workforce and aimed to present "sanitised" information on future employment levels to the Moldovans. The potential for tobacco industry privatisation to undermine tobacco control and promote cigarette consumption is highlighted and is consistent with economic theory. Countries planning tobacco industry privatisation should ensure a transparent and competitive privatisation process, seek to prevent the predicted increase in consumption by implementing effective tobacco control policies and consider the impacts on employment. Multilateral financial organisations promoting tobacco industry privatisation could ensure their loan conditions protect public health by making the implementation of tobacco control policies a pre-requisite for privatisation.

Female↗
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The whole truth and nothing but the truth? The research that Philip Morris did not want you to see.

The tobacco industry maintained, for many years, that it was unaware of research about the toxic effects of smoking. By the 1970s, however, the industry decided that it needed this information but they were unwilling to seek it in a way that was open to public scrutiny. By means of material from internal industry documents it can be revealed that one company, Philip Morris, acquired a research facility, INBIFO, in Germany and created a complex mechanism seeking to ensure that the work done in the facility could not be linked to Philip Morris. In particular it involved the appointment of a Swedish professor as a 'co-ordinator', who would synthesise reports for onward transmission to the USA. Various arrangements were made to conceal this process, not only from the wider public, but also from many within Philip Morris, although it was known to some senior executives. INBIFO appears to have published only a small amount of its research and what was published appears to differ considerably from what was not. In particular, the unpublished reports provided evidence of the greater toxicity of sidestream than mainstream smoke, a finding of particular relevance given the industry's continuing denial of the harmful effects of passive smoking. By contrast, much of its published work comprises papers that convey a message that could be considered useful to the industry, in particular casting doubt on methods used to assess the effects of passive smoking.

Biomedical Research↗
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Tobacco control policy: the European dimension.

The Royal College of Physicians has long played an important role in the struggle against tobacco. As tobacco is a legally traded substance, its regulation increasingly takes place at a European level, where governments seek to balance concerns about public health and free trade. Consequently, it is essential that those seeking to reduce the toll of tobacco-related disease understand the nature of the debate at a European level, in particular the strategies being pursued by the tobacco industry to undermine efforts to promote public health. After describing the European legislative process, this paper explores the current European debates on advertising restrictions, warning labels and cigarette composition, bans on public smoking, taxation, alleged industry involvement in smuggling, and subsidies for tobacco producers. It concludes by examining areas where the College might take action.

Europe↗
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Responding to the challenge of chronic diseases: ideas from Europe.

Health systems everywhere face increasing challenges in responding to chronic disease. This paper explores the nature of these challenges, including the increasing burden of chronic disease and the weak evidence that informs clinical and policy responses. It then describes a series of innovations in different parts of Europe that seek to address these challenges: nurse-led clinics; mechanisms to bridge health and social care; and two more comprehensive programmes, Disease Management Programmes in Germany and national service frameworks in England. Finally it discusses how to overcome the barriers to change and the scope for learning from international experience.

Chronic Disease↗
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Understanding population health: lessons from the former Soviet Union.

The collapse of the Soviet Union was a massive natural experiment that has provided many insights that help our understanding of the determinants of population health. This paper identifies a series of lessons learnt from this experience: (1) Rapid transition can damage health. (2) When undertaking comparative research, it is essential to have a common understanding of what different terms mean in different places. (3) When looking at exposures and outcomes, it is important to appreciate that the delay between exposure to a risk factor and the appearance of disease can range from almost none to several decades. (4) Contrary to the views of some commentators, modern healthcare has made a substantial contribution to the health of populations in industrialised countries. (5) Science can flourish only where it is free from ideology. (6) Public health and basic science achieve most when they work together. (7) Without functioning democracy, the outlook for better health is poor.

Alcoholism↗
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Regulating medicines in Europe: the European Medicines Agency, marketing authorisation, transparency and pharmacovigilance.

Following a review process lasting almost four years, and culminating in several pieces of new European legislation, adjustments have been made to the European Union's (EU) regulatory framework for pharmaceuticals. The European Commission laid out its priorities for the review as: simplifying the authorisation system, ensuring a high quality of public health, completing the internal market in medicines, and preparing for the enlargement of the Union. Amongst the most important changes brought about by the new rules are those relating to the European drug approval procedures, the functions and operational transparency of the European Medicines Agency (EMEA), and the EU's pharmacovigilance system. This article provides a brief examination of key elements of these changes, and considers the extent to which they serve the goal of improved public health protection within the EU.

Drug Approval↗