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PubMed1988

Reforming the law in action through empirically grounded civil commitment guidelines.

Some assumptions that guided the national task force in developing the Guidelines for Involuntary Civil Commitment are identified and discussed. The task force's multidisciplinary membership is seen as enhancing the credibility of the suggested reforms. The task force developed guidelines instead of a model law, avoiding disputes about the philosophical basis of commitment laws and providing local jurisdictions the liberty to adapt the task force's recommendations to suit local conditions. Both the problems identified and the suggestions offered by the guidelines were based on the empirical experience of local commitment systems. Communication among the components of civil commitment systems was seen as crucial to reform and as achievable through a recommended structural change.

Advisory Committees↗
PubMed1990

Training of village health workers in Tanzania; a comparison of two approaches.

The paper compares the costs of training for two groups of Village Health Workers (VHWs) in Tanzania, where the policy of developing a system based on Primary Health Care principles will require the training of more than 16,000 VHWs during the next decade. In the Kilombero District, one group of VHWs was trained according to the guidelines of the National Programme of the Ministry of Health, and another group followed the training programme of the Kilombero Project, based on the Swiss Tropical Institute Field Laboratory. The training scheme of the Kilombero project cost almost 80% less for one VHW, largely because it depended on on-the-spot training by local staff. The results of a first investigation of the efficacy of the training were encouraging; a long-term evaluation is in progress. The curricula for the two programmes also differed; the Kilombero programme had shorter blocks of theory, interspersed with supervised practical work, and introduced curative medicine earlier in the course. The advantage and disadvantages of the two programmes are discussed, not only in terms of cost but also in terms of their efficacy in training VHWs who will be motivated, efficient and accepted by the community.

Community Health Workers↗
PubMed1995

Transformation of the Canadian Association of University Schools of Nursing.

The purpose of this historical research was to analyze the 1967 restructuring of the Canadian Association of University Schools of Nursing (CAUSN) from a powerless, loose affiliation of individual nurse academics into a potentially powerful association of deans and directors. After its 1967 restructuring, CAUSN became active nationally and collaborated with the Canadian Nurses Association on doctoral education, accreditation for nursing education programs, and baccalaureate entry to practice. It also successfully implemented a national program of voluntary accreditation of baccalaureate education. The transformation of CAUSN was analyzed using primary data located in the Queen's University Archives, Ottawa, Ontario, the Canadian Nurses Association Archives, Ottawa, Ontario, and from selected interviews. Secondary data was used to augment and corroborate interpretation of primary data.

Canada↗
PubMed2006

Voluntary HIV counseling and testing: knowledge and practices in a rural South African village.

The purpose of the study was to identify themes related to voluntary counseling and testing services in a rural South African village. Qualitative research methods using grounded theory approach were used. Data were collected from 20 informants. Participants demonstrated knowledge of the availability of voluntary HIV counseling and testing services in the area; however participants did not utilize the services unless they had signs and symptoms suggesting possible HIV infection. Health providers have a responsibility to ensure that individuals get tested before they are infected so as to educate them about ways to protect themselves against HIV infection.

AIDS Serodiagnosis↗
PubMed1992

The HIV pandemic in Sweden: what do people really think about mandatory HIV testing?

This study examines (1) how the general population of Sweden defines the concept of mandatory HIV testing; (2) what measures people consider should be taken against HIV infected individuals if mandatory testing is introduced; and (3) how the opinion of mandatory testing is affected if people consider the matter from a personal rather than neutral point of view. The two first questions were investigated in personal interviews with 1651 randomly selected individuals aged 16-74 years (Study 1). The third question was investigated in an experimental study among Swedish college/university students (Study 2). A total of 58% of the respondents in Study 1 favoured mandatory HIV testing. Confronted with a situation where mandatory testing is introduced and someone refuses to take a test 40% favoured forced testing and 24% favoured fines. If someone is identified as being HIV infected three out of four recommended action only in case this person exposes others to risk. In Study 2 mandatory testing was not, as could be expected, considered to be more repellent if the issue was viewed from a personal point of view than from a neutral one.

AIDS Serodiagnosis↗
PubMed2005

Cost and efficiency of public sector sexually transmitted infection clinics in Andhra Pradesh, India.

BACKGROUND: Control of sexually transmitted infections (STIs) is an important part of the effort to reduce the risk of HIV/AIDS. STI clinics in the government hospitals in India provide services predominantly to the poor. Data on the cost and efficiency of providing STI services in India are not available to help guide efficient use of public resources for these services. METHODS: Standardised methods were used to obtain detailed cost and output data for the 2003-2004 fiscal year from written records and interviews in 14 government STI clinics in the Indian state of Andhra Pradesh. The economic cost per patient receiving STI treatment was calculated, and the variations of total and unit costs across the STI clinics analysed. Multivariate regression technique was used to estimate incremental unit costs. The optimal number of STIs that could be handled by the clinics was estimated. RESULTS: 18807 STIs were diagnosed and treated at the 14 STI clinics in fiscal year 2003-2004 (range 323-2784, median 1199). The economic cost of treating each STI varied 5-fold from Indian Rupees (INR) 225.5 ( 4.91 US dollars) to INR 1201.5 (26.15 US dollars) between 13 clinics, with one other clinic having a very high cost of INR 2478.5 (53.94 US dollars). The average cost per STI treated for all 14 clinics combined was INR 729.5 (15.88 US dollars). Personnel salaries made up 76.2% of the total cost. The number of STIs treated per doctor full-time equivalent and cost-efficiency for each STI treated had a significant direct non-linear relation (p < 0.001, R2 = 0.81; power function). With a multiple regression model, apart from the fixed costs, the incremental cost for each STI detected and cost of treatment was INR 55.57 (1.21 US dollars) and for each follow-up visit was INR 3.75 (0.08 US dollars). Based on estimates of optimal STI cases that could be handled without compromising quality by each doctor full-time equivalent available, it was projected that at 8 of the 14 clinics substantially more STI cases could be handled, which could increase the total STI cases treated at the 14 clinics combined by 38% at an additional cost of only 3.5% for service provision. CONCLUSION: There is un-utilised capacity in the public sector STI clinics in this Indian state. Efforts to facilitate utilisation of this capacity would be useful, as this would enable more poor patients with STIs to be served at minimal additional cost, and would also reduce the cost per STI treated leading to more efficient use of public resources.

Acquired Immunodeficiency Syndrome↗
PubMed1986

Proposal for a future delivery market for transplant organs.

Improvements in surgical procedures and immunosuppressive practices have greatly increased the range and success rate of organ transplants. Unfortunately, supply does not meet demand, and demand is increasing. This paper documents the current level of unsatisfied demand for several transplantable organs, and argues that the extant system of altruistic organ donation is unlikely ever to provide adequate supply because of lack of incentives to donate and the ambiguity surrounding property rights over transplantable organs. A greater reliance on markets would help attenuate these problems. However, unorganized private spot markets for human organs are likely to be both inefficient and inequitable, and are perceived as morally offensive. A feasible alternative is an organized, publicly operated future delivery market, wherein an individual can contract, for valuable consideration, with a government agency for delivery of a specific organ upon death. The implementation of such a market would encounter difficult (but not intractable) problems such as price determination, the selection of a medium of exchange, and contractual issues, particularly the role of minors in such a system. Finally, it is argued that such a market is superior to the much-discussed compulsory expropriation alternative.

Altruism↗
PubMed1989

The organization of organ procurement.

The American organ procurement system has improved and matured in the last five years. At the same time, the basic challenges facing it have remained substantially the same because the moral and legal framework of the system has not changed. Success at organ procurement continues to depend on the voluntary cooperation of medical professionals and the families of potential organ donors. The generosity of the American public is so great that the primary challenge facing organ procurement agencies is obtaining cooperation from hospitals and medical professionals. This calls for a "marketing" orientation aimed at those hospitals and professionals who are most likely to treat potential donors. The last five years have seen a more general acceptance of this appreciation of the central task of organ procurement. As a result, the overall effectiveness of the system has improved, as measured by the number of organs procured on a per capita basis and by the number of multiorgan donors obtained. Much of this improvement can be attributed to the diffusion of organizational techniques and approaches, and this diffusion has been encouraged by the involvement of national organizations and public bodies in the organ procurement community. The system remains uneven in its effectiveness and further improvement is possible. It is also possible that the next general round of improvement will result from the application of businesslike information management and marketing techniques.

Federal Government↗
PubMed1993

Improving the current system for supplying organs for transplantation.

The United States currently relies on a voluntary, altruistic system for supplying organs for transplantation. It is now generally recognized that this system, as currently operated, produces a seriously inadequate supply of organs. A number of scholars have argued that some type of (generally unspecified) market system is necessary. Two articles appearing in the Journal of Health Politics, Policy and Law have proposed relatively specific market systems for increasing the supply of organs. In this paper we argue that market systems are at best premature. In particular, there is little to suggest that any type of market system for organs will be permitted in the United States in the foreseeable future. We present data that strongly suggest that the current voluntary, altruistic system has not been developed to its full potential and offer a number of specific suggestions for improving the system.

Altruism↗
PubMed1998

Proposal for a mutual insurance pool for transplant organs.

Over the past decade there have been numerous proposals to use market system incentives to attenuate the persistent shortage of transplantable human organs. While shortages have grown, opposition to market-based solutions has remained adamant. Much of the opposition has focused on monetary incentives. This article explores an alternative--a mutual insurance pool to increase the supply of organs. In the process, criticisms of earlier proposals (specifically the future delivery scheme) are addressed, the operation of an insurance pool is described, and problems associated with insurance markets are identified and addressed. The article concludes that an insurance pool could overcome public and political resistance to more explicit market-based solutions.

Attitude to Health↗
PubMed2001

Evidence-based medicine and the law: the courts confront clinical practice guidelines.

This article examines how courts are likely to apply evidence-based medicine, and particularly clinical practice guidelines (CPGs), in healthcare litigation involving quality-of-care and entitlement-to-benefits (coverage) claims. Exploring the "politics" of the current situation, it observes that, just as clinicians have been reluctant to use CPGs in practice, courts have been, and likely will continue to be, slow to apply them in deciding cases., The article analyzes extant and proposed statutory approaches to legitimizing and promoting courts' use of CPGs. It concludes by renewing the author's earlier and controversial proposal to establish a voluntary federal program for certifying guidelines and directing courts to give certified CPGs greater weight in healthcare litigation.

Certification↗
PubMed2006

High HIV prevalence among patients choosing anonymous and free testing in Belgium, 1990-2002.

From 1990 through 2002, 25,250 anonymous and free HIV tests were performed at a testing site, which carried out the majority (85%) of anonymous testing in Belgium. During the same period, approximately 7.3 million confidential tests were registered nationwide. The rate of new HIV infections diagnosed at the anonymous testing site was 11.1/1000 tests; it was significantly higher than the rate observed among confidential tests (relative risk = 7.41; P < 0.0001). New HIV cases diagnosed through anonymous testing include a higher proportion of young adults (42.0% versus 32.5% in confidential testing; P < 0.001) and a higher proportion of men who have sex with men (32.7% vs. 25.9% in confidential testing; P < 0.02). Anonymous and free HIV testing was particularly sought by persons with higher infection risk, and efficiently contributed to HIV diagnosis in this population. Anonymous and free testing should be and remain an accessible alternative integrated in HIV testing policies.

Belgium↗
PubMed1992

For better or worse? The moral and policy lessons of Minnesota's HealthRight legislation.

Minnesota's recently enacted HealthRight legislation places the state at the forefront of American health reform. How did the state manage to overcome the policy gridlock in evidence in other states and at the national level? And how well does the legislation fare under close ethical scrutiny? Among the most important factors that permitted Minnesota to enact reforms were the explicit linkage in the legislative debate of the goal of cost containment to the desire to expand access, the public perception that HealthRight is incremental and consistent with earlier reform efforts in Minnesota, and the lengthy public debate that preceded the enactment of HealthRight. Although it endeavors to create a fair and efficient health care system, it is not at all certain that HealthRight, in its present form, will achieve these normative goals.

Cost Control↗
PubMed1996

Routine HIV testing of hospital patients and pregnant women: informed consent in the real world.

The Centers for Disease Control and Prevention (CDC) has recommended that HIV testing be routinely offered to certain patients in hospitals with a high prevalence of HIV infection and on all pregnant women. The CDC does not, however, offer implementation level guidelines for obtaining informed consent. We provide a moral justification for requiring informed consent for HIV testing and propose guidelines for securing such consent. In particular we argue that genuine informed consent can be secured without elaborate counseling, such as that currently used at Counseling and Testing Sites, provided that sufficient written notice is given to the patients before testing and that they are specifically asked for permission.

Centers for Disease Control and Prevention, U.S.↗