Health Policy

New actors on the international health scene have emerged, challenging WHO's leadership in global health. The role and functions of WHO have been questioned. Changes in financing have eroded the influence of the governing bodies. The Nordic countries, which together provide a considerable share of the total voluntary contributions to WHO, have recently made a number of studies of WHO, pinpointing weaknesses and proposing reforms. A slow reform process is also taking place within WHO. The main conclusions from these studies are analyzed and the areas with the greatest need for reform are studied. This paper presents proposals for the far-reaching reforms needed for WHO to recapture its leadership role in international health.

The purpose of this paper is to derive annual estimates of the aggregate dependency of the nursing home population in Australia, and to use these data to consider the impact of Government policies to target nursing home services to those with high care-needs/dependency. Two related tools, the 'Aggregate Dependency Value' and 'Aggregate Dependency Index', have been constructed using the principles of case-mixed based systems, to quantify the aggregate dependency of residents. Data on all residents 1968-1969 to 2006-2007, and on newly admitted residents 1992-1993 to 2006-2007 have been derived and analysed. To construct the tools, the percent of residents classified into various dependency categories were weighted by proxy measures of their dependency. These were summed, and converted into index numbers to estimate rates of change in the aggregate dependency of residents. The derived data were used to consider possible impacts of the policies. The data indicate that the dependency of residents has, for the most part, increased over recent decades but that the rate of the increase has varied. An increase in the dependency of residents corresponds with the policies' objectives. The tools extend the ways the dependency of nursing home residents in Australia can be assessed. The estimates support the effectiveness of the Government's targeting policies but causal relationships have not been estimated.

Team-based practice in primary care has been advocated for improved access, quality, effectiveness, and cost-efficiency of primary health care services, but there is limited empirical evidence supporting it. To examine the impact of team-based practice on patients' perception of several process and outcome indicators from patients' perspective. Micro data from the 2007-08 Canadian Survey of Experiences with Primary Health Care conducted by Statistics Canada were utilized. Regression techniques and propensity score matching method were used to examine the impact of team-based primary care on several process and outcome indicators of primary care. The estimated average treatment effect of team-based care was positively significant and robust for access to after-hours care, quality of care, confidence in the system, overall coordination of care, and patient centeredness. Although the estimated average treatment effects for the two dimensions of follow-up coordination, continuity of care, health promotion and disease prevention initiatives, and utilization of physician and nurse services were statistically significant, sensitivity test results showed that these results were unreliable. Team-based primary care improves patients' perception of process and outcome indicators in the area of access to after-hours care, quality of care, confidence in the system, overall coordination and patient centeredness. Future research needs to establish the causal link between team-based primary care and health outcomes of patients.

The aim of this study is to describe the development of quality management systems in Hungarian hospitals. It also aims to answer the policy question, whether a separate patient safety policy should be created additional to quality policies, on national as well as hospital level. In 2005, a questionnaire survey was conducted to evaluate the existing quality management systems in all Hungarian hospitals. The relationship between the level of the development of quality management systems, the certification status and the current level of patient safety activities was investigated using linear regression. Quality was measured with the quality management system development score (QMSDS), and patient safety by the number of patient safety activities. 102 of 134 (76%) of the hospitals have returned the questionnaire. The average hospital has 24.5 of 35 core quality activities, and 4 of 11 patient safety activities. There is a statistically significant but weak relationship between the QMSDS and the number of patient safety activities, explaining 12% of the latter's variance. Certification (International Standards Organisation (ISO) and professional standard based) is not significantly related to patient safety. In our study quality by QMSDS is weakly related; however, certification is not significantly related to patient safety. We conclude that separate patient safety policies seem worthwhile to be created for the hospital sector in addition to the ongoing quality improvement efforts in Hungary.

The present paper aims at giving a short overview of the organization and financing of the Danish health care system as of 1997-1998 when the SWOT panel evaluated the system. The overview follows the triangular model of a health care system. The Danish system is characterized by being decentralized and single-funded. The hospital sector is public, and hospitals are financed and run by the counties (with only a very small private hospital sector alongside). General practitioners are private entrepreneurs but work under contract for the counties. Hospitals are financed by global budgets, while general practitioners are paid by a mixed remuneration system of capitation fees and fee-for-service. During the past 20 years, the government has repeatedly imposed budget ceilings on the counties which has limited growth in the health care sector.

There is a widespread perception that developed countries in the Western world dictate the shaping and governance of global health. While there are many bodies that engage in global health governance, the World Health Organisation (WHO) is the only entity whereby 194 countries are invited to congregate together and engage in global health governance on an equal playing field. This paper examines the diversity of governance within the World Health Assembly (WHA), the supreme decision-making body of the WHO. It explores the degree and balance of policy influence between high, middle and low-income countries and the relevance of the WHO as a platform to exercise global governance. It finds that governance within the WHA is indeed diverse: relative to the number of Member States within the regions, all regions are well represented. While developed countries still dominate WHA governance, Western world countries do not overshadow decision-making, but rather there is evidence of strong engagement from the emerging economies. It is apparent that the WHO is still a relevant platform whereby all Member States can and do participate in the shaping of global health governance. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

This article analyzes policies that affected the availability of praziquantel, the drug of choice for schistosomiasis. The study examines how interactions among four actors (pharmaceutical producers, international agencies, non-governmental agencies, and national governments) affected praziquantel availability in poor countries. It also examines trends in praziquantel prices over time in different markets. This analysis demonstrates that the discovery of an effective new drug does not necessarily result in access to the drug for disease sufferers--especially if those sufferers are poor people in poor countries. The article proposes measures to improve international systems for making new drugs available in poor countries.

For the past two centuries or so, the emergence and growth of scientific medicine has resulted in the gradual replacement non-scientific medical practitioners with scientific medical practitioners at the field of public health in most Western countries. The key factor behind this transformation has been the official policy that has encouraged practitioners of scientific medicine while at the same time suppressing and ignoring practitioners of non-scientific medicine. The case of the Republic of Korea (henceforth called Korea) reveals, however, a small discrepancy from this general trend, i.e. the coexistence of practitioners of both non-scientific medicine and scientific medicine. This article explores the modernisation of the system of Traditional Korean Medicine from 1876 to 1990 in an attempt to answer why the Korean health care system has a dual system of medical care and argues that the dual system of medical care in Korea was shaped by the conflicts and tensions between herbal doctors and Western trained doctors throughout the various stages of historical development.

The results of the doctor distributional policy in Mexico is evaluated. Despite the government's efforts to achieve a better distribution of doctors throughout the country between 1930 and 1990, important disparities still exist among geographic areas. Diverse factors ranging from the underdevelopment of some areas, to the resistance of doctors to leave the urban areas, are related to this unequal distribution. Early programmes aimed at redressing the original distribution in the 1930's had limited effects. In subsequent years, additional programmes were implemented. However, a lack of coordination and the short time span of many programmes produced only minor changes to the distributional pattern. Although in recent years the distribution has improved, southern states still suffer an acute scarcity while northern states have a relative abundance. Finally, the paper discusses how economic, political and social variables, as well as the structure of the health system, have shaped the current distribution of Mexican doctors.

Determinants of universal healthcare (UHC) are poorly empirically understood. We undertook a comprehensive study of UHC development using a novel Evidenced Formal Coverage (EFC) index that combines three key UHC elements: legal framework, population coverage, and accessibility. Applying the EFC index measures (legislation, ≥90% skilled birth attendance, ≥85% formal coverage) to 194 countries, aggregating time-varying data from 1880-2008, this study investigates which macro-economic, political, and social indicators are major longitudinal predictors of developing EFC globally, and in middle-income countries. Overall, 75 of 194 countries implemented legal-text UHC legislation, of which 51 achieved EFC. In a country-year prospective longitudinal analysis of EFC prediction, higher GDP-per-capita (per GDP-per-capita doubling, relative risk [RR]=1.77, 95% CI: 1.49-2.10), higher primary school completion (per +20% completion, RR=2.30, 1.65-3.21), and higher adult literacy were significantly associated with achieving EFC. Results also identify a GDP-per-capita of I$5000 as a minimum level for development of EFC. GDP-per-capita and education were each robust predictors in middle-income countries, and education remained significant even controlling for time-varying GDP growth. For income-inequality, the GINI coefficient was suggestive in its role in predicting EFC (p=0.068). For social and political indicators, a greater degree of ethnic fractionalization (per +25%, RR=0.51, 0.38-0.70), proportional electoral system (RR=2.80, 1.22-6.40), and dictatorships (RR=0.10, 0.05-0.27) were further associated with EFC. The novel EFC index and this longitudinal prospective study together indicate that investment in both economic growth and education should be seen of equal importance for development of UHC. Our findings help in understanding the social and political drivers of universal healthcare, especially for transitioning countries.

The purpose of this study is to provide information from two prospective long-term follow-ups for severe road traffic injuries in Sweden. The long-term consequences, in terms of loss of health and costs of care, are presented for severe injuries in Sweden in the early 1990s and are compared with information on injury severity and health care utilisation 25 years ago. The follow-up in the 1990s show that, 1 year after the accident 38% of the non-fatal adults were suffering of some functional disability, pain and distress. Adults suffering from long-term loss of health decreased to 23% on average 3.7 years after the accident. The average health care cost was estimated to SEK46200 (in 1995 prices), and the average in-patient care was 10 days. However, when also including subsequent expected life-long care for three severely injured patients, the average incidence-based health care cost was estimated to SEK100300. In the 4-5 year follow-up 25 years ago, severe traffic injuries were treated on average 21 days in hospital and 38% of the adults were still suffering from long-term physical effects. Conclusions to be drawn are that treatment in hospital of severe traffic injuries has shortened by half and long-term consequences have not been worsened. Our results indicate that long-term effects do not cause as serious loss of health nowadays as they did 25 years ago.

Objective: To demonstrate the utility of rates of change in measuring country performance in health using the rate of decline of adult mortality for 22 countries in the OECD as an illustration. Methods: We used adult mortality (the probability of dying between ages 15 and 60) for 1970-2010 by country as our outcome measure. We assessed and ranked country performance in rates of decline of adult mortality for four decades, and compared this to performance in levels of adult mortality. Principal findings: We identified best and worst performers, and identified changes in performance. For example, for female adult mortality (FAM): in the 1970s, the top performer in the rate of decline was Japan and the worst performer was Denmark; in the 2000s, the top performer was Portugal and the worst performer was the United States. The Netherlands saw the largest improvement in the rate of decline of FAM, from 1991-00 to 2001-10. Finland showed the greatest decrease, from 1971-80 to 1981-90. We found little correlation between performance in rates of decline and performance in levels of FAM. Conclusions: Examining the rates of change of health indicators at the country level enables finding transition times in performance, and provides a more time-sensitive measure of country performance than does assessing performances in levels of health. The effects of changes in potential determinants of health can then be assessed in terms of their relation to transition times in performance.

To describe community-driven alcohol policy for 78, primarily First Nations, Métis and Inuit, communities in Canada's three northern territories (Yukon, Northwest Territories and Nunavut) between 1970 and 2008. This is a first step to understanding the policy-oriented prevention system that has evolved in these areas over time. Regulatory data were compiled from Part II of the Territorial Gazette Indices and the Revised Statutes and Regulations of each territory. Regulations were categorized as open, restricted, prohibited or other. The number of communities with some form of regulation has increased steadily over time with half of the sample communities adopting some form of regulation between 1970 and 2008. The use of prohibition as a policy choice peaked in 1980 but has remained relatively steady since that time. There has been a steady increase in the adoption of other kinds of restrictions. Communities with regulations tend to have smaller and younger populations, a greater percentage of people with First Nations, Métis or Inuit origin and are more geographically isolated than those with no regulation. This is the first time alcohol control policies have been compiled and described for the Canadian north. The dataset records the collective energies being put into community problem solving and provides a means to interpret the prevalence of health and social problems linked to alcohol use in these communities over time.

Objective: To analyse the trends and characteristics of international health issues through agenda items of the World Health Assembly (WHA) from 1970 to 2012. Methods: Agendas in Committees A/B of the WHA were classified as Administrative or Technical and Health Matters. Agenda items of Health Matters were sorted into five categories by the WHO reform in the 65th WHA. The agenda items in each category and sub-category were counted. Results: There were 1647 agenda items including 423 Health Matters, which were sorted into five categories: communicable diseases (107, 25.3%), health systems (81, 19.1%), noncommunicable diseases (59, 13.9%), preparedness surveillance and response (58, 13.7%), and health through the life course (36, 8.5%). Among the sub-categories, HIV/AIDS, noncommunicable diseases in general, health for all, millennium development goals, influenza, and international health regulations, were discussed frequently and appeared associated with the public health milestones, but maternal and child health were discussed three times. The number of the agenda items differed for each Director-General's term of office. Conclusions: The WHA agendas cover a variety of items, but not always reflect international health issues in terms of disease burden. The Member States of WHO should take their responsive roles in proposing more balanced agenda items.

The average length of stay (LOS) is considered one of the most significant indicators of hospital management. The steep decline in the average LOS among Japanese hospitals since the 1980s is considered to be due to cost-containment policies directed at reducing LOS. Japan's hospital sector is characterised by a diversity of ownership types. We took advantage of this context to examine different hospital behaviours associated with ownerships types. Analysing government data published from 1971 to 2008 for the effect of a series of cost-containment policies aimed at reducing LOS revealed distinctly different paths behind the declines in LOS between privately owned and publicly owned hospitals. In the earlier years, private hospitals focused on providing long-term care to the elderly, while in the later years, they made a choice between providing long-term care and providing acute care with reduced LOS and bonus payments. By contrast, the majority of public hospitals opted to provide acute care with reduced LOS in line with public targets.

To outline the principles underlying changes overtime in entitlement to sickness absence benefit in Denmark. The Danish sickness benefit scheme during the past 30 years has been studied based on a comprehensive review of the Sickness Benefit Act from 1973, and all later amendments to the act. Entitlement to sickness benefit in Denmark has undergone considerable changes during the past 30 years. The guiding principles of the reforms have been financial savings in combination with an assumption that human behaviour can be controlled through bureaucratic administration with focus on monitoring and evaluation. The Sickness Benefit Act was initially based on a broad concept of disease but the implementation underwent major changes. In the 1970s and 1980s entitlement to benefit depended very much on medical diagnosis. This practice changed and today's policy is to some extent a return to the biopsychosocial approach in the sense that the citizen is not regarded a passive victim of disease but an active player in influencing own working capacity. Added to this is, however, a new element of much tighter control leaving less room for autonomy.

To quantify the magnitude of geographical health inequality by sex and age group, and to observe the change in regional distribution of health disadvantage, this study estimated excess deaths attributable to the mortality variation among municipalities across Japan from 1973 through 1998. The municipalities (N = 3340 in 1995) were divided into quintiles according to standardized mortality ratio (SMR). Using the mortality of the lowest SMR quintile as the standard, the number of excess deaths (ED) and its ratio to observed deaths (EDR) were estimated by sex, age group (total population and under 65-year population) and regional block in 1973-1977, 1978-1982, 1983-1987, 1988-1992 and 1993-1998. Total annual ED in 1993-1998 was estimated as 47,124 for males and 46,562 for females, representing EDR of 9.9 and 11.6%, respectively. The under 65-year population had a higher EDR than the total population. Rural regions showed a marked decrease in EDR in contrast to the increase in urban regions over time. The present study suggests that the reduction of a large number of deaths, especially premature deaths, is expected by elimination of geographical health inequality, and that health policies for urban residents are prioritized.

The health care policy issue regarding the balance between public and private health spending is examined. An empirical model of the determinants of the public-private mix in Canadian health care expenditures over the period 1975-1996 is estimated for total health care expenditures as well as separate expenditure categories such as hospitals, physicians and drugs. The results find that the key determinants of the split are per capita income, government transfer variables and the share of individual income held by the top quintile of the income distribution. Much of the public-private split is determined by long term economic forces. However, the importance of the federal health transfer variables and the variables representing shifts in fiscal transfer regimes suggest the increase in the private share of health spending since 1975 is also partly the result of the policy choice to reduce federal health transfers.

This article is intended to stimulate debate. Where does public health planning in developing countries need to go if it is to focus on the challenges of meeting the health needs of the poor and increasing the accountability and performance of health services? The article concludes that Alma Ata vintage public health planning has frozen many health ministries in a non-monetarised world. The effects, are systematic obstacles to using many technologies available in other sectors to improve accountability and performance through better business planning and control. High time for an Alma Ata II Conference.

From 1980 to 1984 Americans with no health insurance increased from 13.9% to 17.1% of the non-elderly population. Non-elderly persons covered by Medicaid declined from 6.2% to 5.6%. Previous studies of the share of the burden of uncompensated care borne by various provider groups present opposing findings. The National Hospital Discharge survey data presented here demonstrate that for-profit hospitals serve significantly lower percentages of uninsured discharges than secular or church-affiliated non-profit hospitals and public hospitals. The same pattern of differentials is observed with respect to Medicaid. On the whole the results of the survey tend to support the argument that private non-profit hospitals do indeed render greater public services in treating indigent patients than do for-profit hospitals. It must also be emphasized, however, that the results show all private hospitals falling somewhat short of the standard set by public hospitals in treating indigents. Thus, the continued shrinkage of the public hospital sector has serious policy implications.

Life expectancy at birth in southern Europe is known to be greater than expected in comparison with levels of economic development. This has been attributed to the 'Mediterranean diet'. There are, however, concerns that this comparative advantage is being lost. This paper examines the factors underlying changing life expectancy in Italy since 1980. The subjects of this analysis are obtained from data on all deaths in Italy between 1980 and 1992. Change in age specific death rates is calculated from selected causes and, using the method developed by Pollard, the contribution of deaths from different causes and at different ages to changing life expectancy at birth is estimated. Between 1980 and 1992, life expectancy at birth increased by 2.70 years for men and 2.75 years for women. Death rates have fallen among children and those over 40. In contrast, death rates have increased among men aged between 20 and 39 and have increased very slightly among women aged 25-29. Falling death rates from ischaemic heart disease are continuing to contribute to increasing life expectancy. Death rates from lung and breast cancer are rising among women but are compensated for by falling death rates from other cancers. Among men, falling death rates from cancer at younger ages are being offset by increases at older ages. The rising death rate among younger men is almost entirely due to AIDS, with accidents also making a small contribution. Life expectancy in Italy has improved throughout the 1980s, largely driven by falling death rates from cardiovascular diseases. Here are, however, some worrying trends, most notably the rising death rate among young men, due almost entirely to AIDS. The changing pattern of mortality has some similarities with Spain, another Mediterranean country, but there are also important differences.

This paper provides an empirical investigation of the economic cost of illness, disability and premature death in the Federal Republic of Germany in the year 1980. Direct and indirect cost of morbidity and mortality are estimated and allocated to the disease categories of the ICD-International Classification of Diseases. Against the background of increasingly scarce resources in health care, the findings of cost of illness studies obtain special significance for the setting of priorities for the allocation of these resources. In comparison to the status quo, a disease-oriented approach may provide a more differentiated and national basis for the ex-ante macro-allocation of health care resources as well as for the identification of areas for increased efforts in prevention.

The rising cost of treating hypertension has become an issue of concern in several countries, including the United States, parts of Europe, and more recently, New Zealand. In New Zealand between 1981 and 1987, the total inflation-adjusted expenditure on antihypertensive drugs increased by 61.7%, from $21.4 million to $34.6 million in constant 1981 dollars. The major part (56.3%) of this increase in overall expenditure was explained by the rise in real cost of drug treatment, while the number of patients on drug therapy remained virtually static over the same period. The average cost of a prescription for hypertension was estimated to have risen by 46.1% between 1981 and 1987, i.e. from $7.30 to $10.66 in constant 1981 dollars. Pardoxically the mean inflation-adjusted price of antihypertensive drugs fell by 10.8% over the same period. Changing patterns of prescription and the entry of new drugs into the market accounted for most of the rise in average cost per prescription over the study period. Unless the rising expenditure can be justified by demonstrable improvements in treatment outcome, continuation of these trends will have profound effects on the cost-effectiveness of antihypertensive therapy.

In this study of the Western Australian population we analysed changes in the demographic determinants of PHI use across health policy eras. Specifically, we aimed to predict the probability that an individual, defined by a pre-determined set of characteristics, would utilise PHI for in-patient hospitalisation in WA in each of five health policy eras spanning 1981-2001. The WA Data Linkage System was used to extract hospital morbidity data from 1 January 1981 to 31 December 2001. Random effects logistic regression analysis was used to estimate the likelihood of utilising private health insurance in each of five health policy eras based on the timing and composition of changes in federal health care policy. The use of PHI for in-patient hospitalisation fell significantly from 1981 to 1997 (61% above to 53% below the odds of being a public patient). From 1999, however, the odds of using PHI substantially increased to 16% above that of being a public patient. The likelihood of using PHI in all age fell approximately exponentially across successive health policy eras compared with that in the oldest (70+ years) age group. From 1997 onwards, the relative probabilities of average and disadvantaged individuals using PHI substantially increased compared with extremely advantaged individuals. Our study found that the overall likelihood of utilising PHI versus utilising Medicare for in-patient hospitalisation, adjusted for all demographic characteristics, decreased between 1981 and 1998 but increased precipitously after 1999. We also found that the determinants of using PHI have changed significantly across health policy eras. The most significant changes occurred with respect to age (the probability of PHI use by older individuals increased) and socio-economic status (the probability of PHI use by average and disadvantaged individuals increased). This shift in the effects of determinants of PHI suggests that the introduction of the recent health policies were associated with a change in both the age and socio-economic profile of individuals who utilise PHI.

The proportion of female doctors is increasing. Yet, there is little evidence that demonstrates changing career preferences over a long period, nor do we know the long-term impact of changing male-female ratios in medicine. We explored this within the GP profession. By means of a longitudinal cohort study (postal questionnaires) among all graduated GPs in the Netherlands between 1982 and 2001 we explored trends in career preferences and investigated whether practice preferences of men and women differ over the years. Preference of becoming a GP has significantly decreased among men. GPs prefer group practice more than solo practice. Female doctors were more likely to prefer a small practice and to associate. Men prefer to take over an established practice. Main reasons to abstain from practicing as a GP for men were having found another job or not having found a practice according to their preferences. Main reasons for women were having decided for another job and family life. We conclude that male and female GPs select differently on practice setting. Preferences change through the years but tend to converge. Gender differences are likely due to the circumstance that career choices for men are more influenced by fluctuating labour markets, while female choices are more based on family circumstances. We expect that as more women will become a GP the demand for small group practices will increase. Also, as many female GPs abstain from practicing after having finished a vocational GP training program it will be essential to create work facilities to keep them available for the GP labour market.

The function of the hospital geriatric service in the U.K. is described within the context of the overall support for the frail, disabled, and sick elderly in this country. It plays an important part in the secondary care of the very old, and perhaps an even more important part educating the public and the profession to the needs of this rapidly expanding section of the population. A short account is given of the nature of geriatric medicine and the role of the consultant geriatrician. The history, achievements, and current status of the specialty are briefly reviewed, and some of the directions which future developments may take are indicated. Whether or not a comprehensive separate service on the U.K. model emerges in other countries, it is certain that they will need centres of geriatric expertise to pursue research and to provide education and enlightenment for all concerned with the medical problems of old age.

The percentage of females in the physician workforce is increasing in Japan, as in other countries; however, the working status of female physicians has not been sufficiently investigated. Original data were obtained from the National Survey of Physicians (NSP) conducted by the Ministry of Health, Labour and Welfare, Japan, from 1984 to 2004. We examined the trend of female physicians' areas of practice and analyzed their leave, return to work, and change in areas of practice using cohort data. The percentage of female physicians has increased significantly in recent generations, especially in surgery, surgical subareas of practice, and obstetrics and gynecology. A remarkable increase was found in obstetrics and gynecology among women under 29 years old from 15.4 to 66.2%. The total number of female physicians on leave has been higher than the number of female physicians returning since 1998. The average percentage of those who changed their area of practice was high in surgery (20.7%) and low in pediatrics (5.0%) and obstetrics and gynecology (1.7%). A strategic plan is needed for future health policy to plan for the physician workforce, especially for the areas of practice with increasing proportions of young female physicians.

Objective: To explore trends and income related differences in out-of-pocket (OOP) costs for prescription and over-the-counter medicines in Finland in 1985-2006. Methods: Cross-sectional data collected in Household Budget Surveys conducted in 1985, 1990, 1995, 2001 and 2006 were used to calculate trends in household OOP payments in absolute and relative terms. Covariance analyses were used to evaluate age-adjusted OOP costs across income groups. Results: Mean OOP costs per household increased 2.7 fold over inflation from 1985 to 2006. The growth was steepest (60%) in 1990-1995 and slowest (10%) in 1995-2001. The mean costs, in 2006 currency value, increased from €138 to €373 and the average share of household total consumption spent on medicines increased from 0.8% to 1.6%. After adjusting by age, the lowest income quintile had the lowest mean OOP costs for all types of medicines at every time point, although the overall differences were small. In 1985/2006, the age-adjusted estimated marginal means for household medicinal costs were €121/€332 for the lowest income quintile and €138/€449 for the highest quintile, and for the share of household consumption 1.1%/2.2% for the lowest and 0.5%/1.1% for the highest quintile. Conclusions: All patients faced increasing OOP payments for medicines throughout the study period, but the relative growth was largest for the lowest income groups. Our results suggest that savings achieved by increasing the patients' share of costs coincided with steep growth in OOP costs and wider differences between income groups. Cost containment measures targeted at prices, on the other hand, coincided with stabilised OOP costs and decreasing dispersion between the income quintiles. More research is needed to evaluate whether differences in OOP costs reflect differences in patterns of use.

There is in Sweden a lack of national data connecting public care services to needs in various sub-groups. As result of these statistical deficiencies there has been a severe lack of solid facts to guide the public debate in Sweden concerning the developments of the old age care system. Also connected to this are the similar problems of predicting future needs development in order to estimate future burdens on the systems of care. A computer model has been developed that, by combining different national and local data sources, describes the development of the Swedish public system of care for older persons in terms of service provision and costs per needs group according to age, gender, marital status and degree of disability or ill-health. The model works in 5-year steps and has a retrospective part covering the period 1985-2000 and a prospective part for the period 2005-2030. In this article is described the structure of the model, assumptions, data sources and results for the retrospective part of the model. The model calculations show that despite of a large increase in the number of older persons there has not been a very substantial increase of needs. The number of persons with severe ill-health is basically unchanged, even if there appears to have been some shift in the composition of the group towards more heavy disability. The reductions in provided services, that the municipalities have been forced to do depending on the harsher economic conditions in Sweden since the beginning of the 1990s, have almost exclusively been targeted on persons with lesser needs. Those most in need have largely been shielded.

By examining the introduction and dissemination of external peer review through site-visits (visitatie) amongst Dutch medical specialists, this paper sets out to deepen our insight into the dynamics of professional self-regulation and health care policy making. We explore how visitatie has been used in the political process between medical specialists and the state, serving as a strategy in protecting the autonomy of physicians. In the late eighties and early nineties, factors both internal as well as external to the medical profession all together determined the start and spread of visitatie. The conflict between state and doctors over the specialists' income, the introduction of the market oriented policies, new visions on quality assurance, the debate on the future of medical specialistic care and a new legal framework on quality assurance, challenged the medical community to find ways to reconfirm the public's trust in the self-regulating mechanism of the profession. One answer is found in carrying out 300-400 visitaties annually. During the past years, many stakeholders have perceived visitatie as a credible instrument in assuring quality patient care. The dynamics of professionalization and measurable impact of visitatie will determine whether or not it is here to stay.

The last decades increasing pharmaceutical expenditures in Sweden and other western countries have created a need for reforms to reduce the trend. The aim was to analyse if reforms concerning the pharmaceutical reimbursement scheme in Sweden during the years 1986-2002 were associated with changes in cost, volume and cost per volume of pharmaceuticals. Effects of changes in the reimbursement schedule during the study period were evaluated for all registered pharmaceuticals in Sweden and for five indicator drug groups. Five policy changes during the study period were assessed. Three concerned increased patient co-payment (January 1, 1991; January 1, 1995 and June 1, 1999), one the introduction of reference based pricing and increased co-payment (January 1, 1993) and one a new structure of the reimbursement schedule (January 1, 1997). The National Corporation of Swedish Pharmacies provided pharmaceutical delivery data for all Swedish pharmacies. Possible breaks in the trend associated with the investigated reforms were analysed with linear segmented regression analysis. This showed that increased co-payments were not associated with changed level or slope of cost and volume. The new reimbursement schedule was associated with a decreased level of cost and volume, both for all drugs combined and for several of the indicator drug groups. It was also associated with an increased slope for both volume and cost in some indicator drug groups and for all drugs. Introduction of reference based pricing was associated with a reduced slope of cost/defined daily doses (DDD) in all of the indicator drug groups and for all drugs. The analysis showed that major changes in the reimbursement system such as the introduction of a new reimbursement schedule and reference based pricing were associated with reductions in cost and volume for the new reimbursement schedule and cost per volume for reference based pricing.

Theoretically, the preferred type of health economic evaluation is the cost-benefit approach in which costs as well as benefits are measured in monetary units. This type of analysis is rarely found in practice, however, where cost-effectiveness analysis (CEA), cost-utility analysis (CUA) and other forms of economic evaluations are instead favored. The use of quality adjusted life-years (QALYs) or life-years gained, if applicable, is generally recommended in CUA/CEA because these measures will make possible broad comparisons with other studies as well as with norms regarding society's willingness-to-pay for health benefits. The purpose of this paper is to study the choice of health outcome measures and the extent to which results from CUA and CEA are discussed from such a willingness-to-pay perspective. Based on the analysis of a sample of 455 studies included in the Health Economic Evaluations Database (HEED), it is concluded that major differences exist in the choice of health outcome measures across disease categories. There is no evidence that QALYs or life-years gained have become more common over the years and CEAs using intermediary outcome measures are as common as those using life-years gained. Furthermore, studies using QALYs or life-years gained often lack a relevant discussion of society's willingness-to-pay per QALY or life-years gained.

Trends in the utilization of various hospital resources by HIV-infected persons between January 1987 and June 1990 have been studied to support health care planning. Data on 126 asymptomatic and symptomatic HIV-infected persons have been recorded at a patient level and analyzed at half-yearly intervals. At a hospital level, increasing utilization trends were observed. At the patient level, a decreasing utilization intensity was measured for admissions, inpatient days, inpatient diagnostic examinations, and outpatient consultations. Increasing utilization intensity was measured for care during admissions. A constant utilization intensity was observed for outpatient diagnostic examinations and inpatient medication days. Use of interventions tended to increase at the end of the study period. Discriminating between trends in the utilization of different hospital resources can improve the management of hospital health care demands of HIV-infected people.

Efficient resource allocation in health care requires adequate techniques of collective decision making. In a recent article Shiell, Gerard and Donaldson (Health Policy 8 (1987) 317-323) claim that cost of illness studies only confuse, mask and mislead, while cost-benefit analysis provides the relevant framework for decisions in health care. We do not agree with their naive approach to decision making in health care. In comparing the two alternative methods, their respective importance for decision making becomes apparent. None of the two techniques may be considered as the one and only means to ultimately solving the problem of efficient resource allocation in health care. Yet, both techniques can provide relevant information on which policy makers can base their decisions in health care.

This article examines the health crisis that followed the diagnosis of 15 cases of poliomyelitis in Israel late in 1988. The article reviews the recommendations, decisions and activities undertaken by the health authorities during the episode. Consequently, it analyses the role in policy making of each of the principal players: the leadership of the Ministry of Health, the professional Advisory Committee and the executive level of the Public Health Service. The conclusion, that changes in policy are expedited by crises, appears to hold for every health system. In Israel those changes were reflected by the introduction of a new immunization policy and, most important, the establishment of a national Ministry of the Environment.

The history, up to 1990, of operational DRG systems in the United States is described from the viewpoint of changes to the patient classification system. Uses of DRGs, the DRG assignment process and the clinical verification steps are also described. The DRG classification process has become more precise over the last decade in both detail and structure. The annual revision process used in the U.S. is outlined with a detailed summary of historical changes. Recent improvements to DRGs have been directed towards a higher degree of precision as regards patient severity and related resource intensity. Recent research into modifying DRGs to better account for complexity or severity is presented with some scenarios for future developments.

This paper reviews the empirical evidence about the effects of the 1990 general practitioner (GP) contract on the provision of medical services in the United Kingdom. A brief outline of the major changes instigated by the 1990 GP contract is given. Studies of the implementation of the changes tend to focus on either trend analysis, cost-effectiveness or medical practice variation. These studies are reviewed and the implications for the efficiency of primary health care are discussed.

A growing number of Swedish county councils have started to develop more flexible methods by which to produce and deliver health services. This paper explores the current status of this reform process both empirically and conceptually. Empirically, it draws upon data obtained by a 1990 questionnaire from all 26 county councils to chart the level of movement across the entire system. Conceptually, it distills from this reform activity a key element that provides an organizational basis for the future, namely the transformation of provider institutions into 'public firms'. The paper concludes that while the precise outcome may be hard to predict, the reform process itself is well underway.

A report by the Swedish National Committee on Gender Disparities in Patient Care (1996) identified many shortcomings in the ability of the health sector to gear patient management and treatment to the specific needs of men and women. To promote gender equity in health care, the Committee presented several proposals relating to research, education, monitoring, and evaluation of health services and the responsibilities of health authorities. In 2002, the Swedish Government authorised the National Board of Health and Welfare to review and analyse gender equity trends in health care. Data from, e.g. the national quality registers, epidemiological health data registers, population surveys, and Patient Trust Boards were compiled to identify gender disparities in the quality and accessibility of health services. The curricula of medical universities and the policies of major research funds were reviewed, as were developments in major fields of health research. The National Board found that many of the gender disparities identified in the 1990s still exist, e.g. access to advanced evidence-based technologies such as coronary interventions. As previously, women account for around 60%, and men for 40%, of complaints, e.g. to the Patients' Advisory Committees. Many of the proposals of the National Committee have not been fully implemented by the national authorities or the county councils. We conclude that promoting gender equity in health care is an important but difficult task for health authorities. To make health services more gender sensitive a combination of strategies, including enforcement by guidelines and regulations, may be needed.

The objective of this article is to compare the development of health policies in three Baltic countries, Estonia, Latvia and Lithuania in the period from 1992 to 2004 and reflect on whether key dimensions of these policies are developing in parallel, diverging or even converging in some respects. The paper identifies the similarity in the overall goals and compares the policy content in primary health care, the hospital sector and financing. We conclude that health policy in Estonia, Latvia and Lithuania has been progressing in parallel towards a Western European social insurance funding model, developing a primary care system anchored on a general practitioner service and lessening the hospital orientation of the pre-1990s system. There is evidence of both convergence and divergence across the three countries and of progress in the direction of EU15 in key health policy and outcome characteristics. These patterns are explained partly by differing starting points and partly by political and economic factors over the 1992-2004 period.

China has made a significant achievement in tackling the TB epidemic over the last decade, due largely to the implementation of directly-observed treatment strategy (DOT). The cure rate of TB cases reached more than 90% for registered TB patients. However, the case detection rate has, unfortunately, been very low (some 30%). Using available information, this paper identifies four main problems facing TB control in China, these are, low case finding, a substantial proportion of TB patients failing to complete standardised treatment, increased proportion of MDR TB patients, and lack of effective TB control among "floating populations". The paper also analyses the possible causes of these problems associated with socio-economic barriers in care seeking, ineffectiveness of TB services, particularly in poor areas, lack of co-operation between health facilities, and weakness of political and financial commitments of local governments to TB control. The paper ends with the discussion of opportunities and challenges facing TB control and makes recommendations for further actions and research.