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PubMedDate not supplied

Epidemiology, health policy, and resource allocation: the Israeli perspective.

Israel represents a developed country as far as demand and consumption of health services are concerned. The analysis of the Israeli health system reveals a significant trend of expansion in the intensity and the utilization of health services as well as an accelerated development of sophisticated technology, while the percentage of Gross National Product used for health expenditure remained constant and even decreased. Competing needs, reflecting population growth, a rapid aging process, new areas of treatment, and changes in use of health services, illustrate the aggravating issue of setting priorities. The permanent dilemma of the health system is oscillation between opposite trends: enlargement of public eligibility and technological capabilities and economic reduction and budget limitations. Is there a possibility that the insufficiencies of the system are built into patterns of thinking of those in the system, into its structure, and into its organization of health services delivery? Does the formulation of health policy influence, in terms of the outcomes of the system, priorities and allocation of resources? Does the process of decisionmaking reflect in an appropriate manner the epidemiologic data? Under the objective constraints, decisionmaking and health policy formulation become critical determinants of the ability to cope more efficiently and effectively with growing and changing needs. The authors suggest an alternative strategy of health decisionmaking that is more instrumental in order to prevent setbacks and to open new horizons for the future.

Epidemiology↗
PubMed1999

Market model fails: linkages between health policy and performance outcomes in western industrial countries.

In recent years, political discourse has sung the merits of the market model as a panacea for escalating health expenditures. While selected market mechanisms may be useful to control spending, there are reasons to question full-scale use of this model to shape health policy. Using the experiences of seven western industrialized countries, the argument developed in this article is that the market model's own assumptions cannot be upheld because ethical, sociological, and political factors underlying health policy make its application impossible. Specifically, a competitive equilibrium does not exist; sale of health care goods and services do not conform to the rules of marketability; and non-increasing returns are not demonstrable. A discussion of health outcome performance and spending data points out the need to attend to equity distributional concerns, state commitment to the health care access, and the extent and breadth of input into health care decision-making as other factors that should be considered.

Developed Countries↗
PubMed2006

Is modern medicine at risk of losing the plot?

Contemporary medicine has much to its credit, but has created an insatiable demand for new technologies and more health services, fed by commercial promotion, professional advocacy and sociopolitical pressure. Total health expenditure at the national level is now almost 10% of gross domestic product and is expected to top 16% by 2020. After recent inquiries into the failings of its public health system, the Queensland Government has committed itself to a 25% increase in expenditure on health over the next 5 years. But will it lead to better population health, and is it sustainable? The return-on-investment curve for modern health care may be flattening out, in an environment of growing numbers of older patients with chronic illnesses, maldistribution of services and hospital overcrowding. A change in thinking is required if current medical practice is to avoid imploding when confronted with the next major economic downturn. Health policy, service funding and clinical training must focus on critical appraisal of the effectiveness of health care technologies and the structure and financing of health care systems. Practising clinicians will be obliged to provide leadership in determining value for money in the choice of health care for specific patient populations and how that care is delivered.

Australia↗
PubMedDate not supplied

[Study of access to health care and drugs in Cameroon: 1. Methods and validation].

During the 1980s, an economic depression and the concomitant decrease in the national health budget modified the population's health behavior. Improvement of the economy since the late 1990s makes it possible to renew the national health policy. To prepare the highly indebted and poor countries' program (HIPC), the Minister of Health and its partners commissioned a survey to measure the population's real access to health care and the factors that determine this accessibility and to propose concrete corrective actions. To fulfill these objectives, the steering committee decided to analyze health care demand, through a national population survey, and supply capacity, through a national survey of pharmacies and other drug dispensers. A survey of persons using medications will also be conducted (Fig.1). Focusing on this component of health care is justified by these findings: 95% of persons feeling ill buy drugs, whereas only 31% consult a physician or other healthcare provider, and half of the average household's health expenditures are for drugs. Financial, geographic, social and quality indicators were defined to measure accessibility and its determining factors (Table 1). The smallest administrative unit, the health area (HA), was chosen as the sampling unit, to enable us to survey together healthcare demand, supply and consumption according to different concentrations of supply and demand . It behaves as a cluster of sampling units of different populations: drug retailers of all sectors, drug users, households, and ill persons within the households. The HA samples include Yaounde and Douala, with urban and rural sub-samples, for which sampling ratios increase with the diversity of supply and demand, according to several pre-defined factors. The study includes 400 HAs, covering more than one third of the population (Table 2). Within these HAs, 900 pharmacies and other formal drug retailers, 709 street vendors, 4,505 households, 2,532 ill persons in these households, 4,121 pharmacy customers and 850 customers of street vendors were surveyed, i.e., more than 13,600 questionnaires. Assessment of data quality shows that the sample is representative of the national population for its socioeconomic characteristics. Its geographic distribution, even after correction, nonetheless favors urban areas, where both supply and demand are high. Generalizing the 3 sub-samples to the national level thus requires caution, especially for the geographic distribution. Other limitations and possible biases are described and evaluated. However, the retrospective demographic and statistic evaluation shows that the samples are representative of their population and that the data quality can be considered good. This article describes the background of this study and justifies its methodological choices. Future publications will analyze the data collected.

Adolescent↗
PubMed2006

Development assistance for health in central and eastern European Region.

OBJECTIVE: We aimed to quantify development assistance for health to countries of central and eastern Europe and the Commonwealth of Independent States (CEE-CIS). METHODS: We used the International Development Statistics database of the Organisation for Economic Co-operation and Development and the database on development assistance for health compiled for the Commission on Macroeconomics and Health to quantify health development assistance to the region, compared to global and overall development assistance. We based our analysis on standard health indicators, including child mortality, life expectancy at birth and health expenditures. FINDINGS: Although total development assistance per capita to CEE-CIS was higher than that for most other regions of the world, development assistance for health was very low compared to other countries with similar levels of child mortality, life expectancy at birth and national expenditures on health. CONCLUSION: The allocation of development assistance for health on a global scale seems to be related far more to child mortality rather than adult mortality. Countries of CEE-CIS have a high burden of adult morbidity and mortality from non-communicable diseases, which does not appear to attract proportionate development assistance. Levels of development assistance for health should be determined in consideration of the region's particular burden of disease.

Child↗
PubMed2005

Health care reform in Portugal: an evaluation of the NHS experience.

Since 1979, the Portuguese health care system has been based on a National Health Service structure that is expected to promote equity, efficiency, quality, accountability and the devolution of power. In this article, we analyse the content and impact of policies designed to reform the system between 1979 and 2002. This article differs from previous studies in that it uses a stage-based framework to evaluate the policy-making process and the impact of health care reform throughout different political cycles. We show that the NHS model has never been fully implemented and that many policies have diverted the system from its original objectives. Different governments have endorsed a progressive split between financing and provision and the institution of 'new public management' rules in public providers. We conclude that most policies put forward by Social Democratic governments have aimed at influencing demand, while Socialist governments have targeted the supply side. These policies have led to increases in health expenditure that have been comparatively more cost-shared by the State under Socialist governments. We show some overriding trends, namely as follows: despite huge improvements in health outcomes, the system is nonetheless lasting to meet its goals, particularly in terms of the equity of access and utilisation; accountability problems, inadequacies in the use of operational reforming tools (such as resource allocation mechanisms) and a lack of mechanisms to promote efficient behaviour, are all associated with cost containment problems. Structural reforms have been undertaken since 2002 and these have offered some potential for improving accountability and efficiency. Nonetheless, the success of these reforms calls for certain conditions that do not seem to have been fulfilled.

Financial Management↗
PubMed1996

The growing dependency in health care. Recent changes in medical technology imports and exports in Turkey.

This study investigates recent changes related to the import and export of medical technology and their results in Turkey. Between 1980 and 1993 the number of medical technology imports in Turkey rose, and there was a parallel rise in its ratio to total imports and health expenditures. In contrast the ratio of medical technology exports to total exports decreased significantly in the same period. The liberalization of foreign trade and the changes of health services toward free market policy has caused growing import of medical technology in Turkey.

Cost Control↗
PubMed1978

Balancing needs with resources: a service-based approach.

A service-based analysis of public sector health expenditure in North Canterbury is presented. The results indicate that the largest share of the $61 million spent by the North Canterbury Hospital Board and the Christchurch District Health Office in 1975-76 was devoted to primary health care, followed by mental health, surgery and medicine. The implications of this approach for the planning and development of health services are discussed and it is suggested that this provides a framework for setting priorities both within and between services.

Health Expenditures↗
PubMed2003

Access to allergy care: implications for quality healthcare and public safety.

Some managed care companies are considering reducing or eliminating coverage for several second-generation antihistamines prescribed to treat patients with allergic rhinitis, chronic idiopathic hives, and other allergy-related conditions. Treatment options for all patients with allergic and immunologic diseases should reflect accepted standards of medical care. Prescription policies limiting coverage and/or use of second-generation antihistamines are medically inappropriate, below current national standards of practice in the field of allergic and immunologic diseases, and may increase health expenditures in the long-term. Any action to reduce or limit coverage will not only diminish the quality of medical care for allergy patients but have significant health and safety implications for the general public.

Anti-Asthmatic Agents↗
PubMed1993

Health spending by state: new estimates for policy making.

A new data set from the Health Care Financing Administration gives estimates of state spending for hospital care, physician services, and retail purchases of prescription drugs, which together account for 70 percent of health expenditures nationwide. Analysis of these data, which are the first uniform state data to be produced for nearly ten years, shows considerable variation among states and among regions in health care spending. The New England and Mideast regions show the consistently highest spending levels for all three categories; the Southwest and Rocky Mountain regions spent the smallest amount (as much as 17 percent below the U.S. average).

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1984

Unemployment and mortality in post-war Scotland.

One of the more controversial topics in the literature examining the influence of unemployment on health is the hypothesised relation between unemployment and mortality. This paper presents a time series analysis of unemployment and mortality in post-war Scotland. Using a variety of model specifications and several measures of the age and duration structure of male unemployment, we find little evidence of a consistent association between unemployment and male mortality from all causes in different age cohorts. Unemployment, however, appeared to be more closely associated with variations in mortality rates and ischaemic heart disease, but the direction of effect was sensitive to the choice of maximum lag length between unemployment and mortality. There was also little evidence that per-capita real incomes or health expenditure exerted a significant influence on mortality. Our general findings and the methodological limitations of macro-studies of the relationship between unemployment and mortality highlight the importance of investigating the health consequences of unemployment using well controlled longitudinal studies of individuals.

Coronary Disease↗
PubMed2005

Smooth quantile ratio estimation with regression: estimating medical expenditures for smoking-attributable diseases.

The methodological development of this paper is motivated by a common problem in econometrics where we are interested in estimating the difference in the average expenditures between two populations, say with and without a disease, as a function of the covariates. For example, let Y(1) and Y(2) be two non-negative random variables denoting the health expenditures for cases and controls. Smooth Quantile Ratio Estimation (SQUARE) is a novel approach for estimating Delta=E[Y(1)] - E[Y(2)] by smoothing across percentiles the log-transformed ratio of the two quantile functions. Dominici et al. (2005) have shown that SQUARE defines a large class of estimators of Delta, is more efficient than common parametric and nonparametric estimators of Delta, and is consistent and asymptotically normal. However, in applications it is often desirable to estimate Delta(x)=E[Y(1)|x]--E[Y(2)|x], that is, the difference in means as a function of x. In this paper we extend SQUARE to a regression model and we introduce a two-part regression SQUARE for estimating Delta(x) as a function of x. We use the first part of the model to estimate the probability of incurring any costs and the second part of the model to estimate the mean difference in health expenditures, given that a nonzero cost is observed. In the second part of the model, we apply the basic definition of SQUARE for positive costs to compare expenditures for the cases and controls having 'similar' covariate profiles. We determine strata of cases and control with 'similar' covariate profiles by the use of propensity score matching. We then apply two-part regression SQUARE to the 1987 National Medicare Expenditure Survey to estimate the difference Delta(x) between persons suffering from smoking-attributable diseases and persons without these diseases as a function of the propensity of getting the disease. Using a simulation study, we compare frequentist properties of two-part regression SQUARE with maximum likelihood estimators for the log-transformed expenditures.

Age Factors↗
PubMed1987

Health status and medical expenditures: more evidence of a link.

The hypothesis that one must include life-style changes in order to accurately capture the true relationship between medical expenditures and health status is explored, using data from 22 countries over a 20-year period. A simultaneous model is estimated using a variety of indicators for life style as well as health status. Changes in life style, aging of the population and changes in occupational risk are modeled as influences on medical expenditures: medical expenditures and changes in life style are modeled as having direct influences on health status. The results are consistent with the existence of a positive link between medical expenditures and health status.

Female↗
PubMed2002

The Danish health system through an American lens.

The organization and financing of the Danish health care system was evaluated within the framework of a SWOT analysis (analysis of strengths, weaknesses, opportunities and threats) by a panel of five members with a background in health economics. The evaluation was based on reading an extensive amount of selected documents and literature on the Danish health care system and a 1-week visit to health care authorities, providers and key persons. The present paper includes the main findings by one of the panel members. Primary care is much more accessible in Denmark than the USA. A mixed capitation-fee-for-service method of paying generalist physicians in Denmark ensures that everyone has a primary care physician and generalist physicians are responsive to providing services quickly, typically same-day appointments. An organized off-hours service ensures accessible care 24 h a day, 7 days a week. Denmark has the highest public satisfaction with health care, reflecting the value placed on accessibility of primary care. Inpatient hospital care consumes a disproportionate share of Danish health expenditures. Global hospital budgets provide little incentive for hospital or surgical productivity. Long waits for hospitalization, especially surgical procedures and cancellation of scheduled surgery, are a source of patient dissatisfaction. Women's health, patient health risk counseling and coordination of preventive and primary care are major weaknesses of the Danish health system. Patients have a choice of primary care physician within a given geographic area and may go to a hospital of their choice. However, patient surveys and feedback are underdeveloped and very little effort has been made to make services responsive to patients' preferences. While innovations in electronic prescribing are noteworthy, further development of health information technology is needed.

Delivery of Health Care↗
PubMed2000

Standard errors for the retransformation problem with heteroscedasticity.

Economists often estimate models with a log-transformed dependent variable. The results from the log-transformed model are often retransformed back to the unlogged scale. Other studies have shown how to obtain consistent estimates on the original scale but have not provided variance equations for those estimates. In this paper, we derive the variance for three estimates--the conditional mean of y, the slope of y, and the average slope of y--on the retransformed scale. We then illustrate our proposed procedures with skewed health expenditure data from a sample of Medicaid eligible patients with severe mental illness.

Aged↗
PubMed1997

Oral health finance and expenditure in South Africa.

The objective of this paper was to examine the cost of oral health in South Africa over the past decade Particular emphasis was placed on the contribution made by medical schemes which is the main source of private health care funding. Some of the problems facing this huge industry were also briefly explored. Primary aggregate data on oral health expenditure were obtained from the Department of Health, Pretoria and from the offices of the Registrar of Medical Schemes, Pretoria. The results show that in 1994, 4.7 per cent of the total health care budget was allocated to oral health. Of this amount, 14.2 per cent came from the state, 71.9 per cent from medical schemes and the remainder calculated to be from direct out-of-pocket payments. Furthermore, real expenditure for oral health by medical schemes grew robustly and almost continuously from 1984 through to 1994, generally outstripping medical inflation.

Dental Care↗
PubMed2005

Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence.

BACKGROUND: The HIV epidemic has caused a dramatic increase in tuberculosis (TB) in East and southern Africa. Several strategies have the potential to reduce the burden of TB in high HIV prevalence settings, and cost and cost-effectiveness analyses can help to prioritize them when budget constraints exist. However, published cost and cost-effectiveness studies are limited. METHODS: Our objective was to compare the cost, affordability and cost-effectiveness of seven strategies for reducing the burden of TB in countries with high HIV prevalence. A compartmental difference equation model of TB and HIV and recent cost data were used to assess the costs (year 2003 USD prices) and effects (TB cases averted, deaths averted, DALYs gained) of these strategies in Kenya during the period 2004-2023. RESULTS: The three lowest cost and most cost-effective strategies were improving TB cure rates, improving TB case detection rates, and improving both together. The incremental cost of combined improvements to case detection and cure was below USD 15 million per year (7.5% of year 2000 government health expenditure); the mean cost per DALY gained of these three strategies ranged from USD 18 to USD 34. Antiretroviral therapy (ART) had the highest incremental costs, which by 2007 could be as large as total government health expenditures in year 2000. ART could also gain more DALYs than the other strategies, at a cost per DALY gained of around USD 260 to USD 530. Both the costs and effects of treatment for latent tuberculosis infection (TLTI) for HIV+ individuals were low; the cost per DALY gained ranged from about USD 85 to USD 370. Averting one HIV infection for less than USD 250 would be as cost-effective as improving TB case detection and cure rates to WHO target levels. CONCLUSION: To reduce the burden of TB in high HIV prevalence settings, the immediate goal should be to increase TB case detection rates and, to the extent possible, improve TB cure rates, preferably in combination. Realising the full potential of ART will require substantial new funding and strengthening of health system capacity so that increased funding can be used effectively.

AIDS-Related Opportunistic Infections↗