The World Health Report 2000 stated that increased public financing for healthcare was an integral part of the efforts to achieve equity of access. In 2009, the Chinese government launched a three-year health reform program to achieve equity of access. Through this reform program, the government intended to increase its investment in primary healthcare institutions (PHIs). However, reports about the outcome and the improvement of the equity of access have yet to be presented.
Stratified sampling was employed in this research. The samples used for the study comprised 34 community health service centers (CHSCs) and 92 township hospitals (THs) from six provinces of China. Collected data, which were publicly available, consisted of the total revenue, financial revenue, and the number of people for the periods covering January 2010 to September 2010 and January 2011 to September 2011. Revenue information for 2009 and 2010 was obtained from China’s Health Statistics Yearbook.
By using indicators such as government investment, government finance proportion and per capita revenue, t-tests for paired and independent samples were used to analyze the changes in government investment.
Government invest large amount of money to the primary healthcare institutions. Government finance proportion in 2008 was 18.2%. This percentage increased to 38.84% in 2011, indicating statistical significance (p = 0.000) between 2010 and 2011. The per capita financial input was 20.92 yuan in 2010 and 31.10 yuan in 2011. Compared with the figures from 2008 to 2010, the gap in different health sectors narrowed in 2011, and differences emerged. The government finance proportion in CHSCs revenue was 6.9% higher than that of THs, while the per capita revenue of CHSCs was higher. In 2011, the highest and lowest government finance proportions were 48.80% (Shaanxi) and 19.36% (Shandong), respectively. In that same year, the per capita revenue of Shaanxi (40.69 Yuan) was higher than that of Liaoning (28.79 Yuan). Comparing the 2011 figures with those from 2008 to 2010, the gap in 2011 clearly narrowed.
In the three-year health reform program, the Chinese government increased its investment to PHIs gradually and significantly. Thus promote equity to access and universal coverage. However, the increase in government investment stemmed from political desire and from the lack of institutionalization of practice and experience. Hence, a mode of financial allocation must be formulated to promote consistency in government input after the three-year health reform program.
Recent developments aiming to standardise and streamline processes of gaining the necessary approvals to carry out research in the National Health Service (NHS) in the United Kingdom (UK), have resulted in lengthy and costly delays. The national UK governmental Department of Health’s Research Governance Framework (RGF) for Health and Social Care requires that appropriate checks be conducted before research involving human participants, their organs, tissues or data can commence in the NHS. As a result, medical research has been subjected to increased regulation and governance, with the requirement for approvals from numerous regulatory and monitoring bodies. In addition, the processes and outcomes of the attribution of costs in NHS research have caused additional difficulties for researchers. The purpose of this paper is to illustrate, through three trial case studies, the difficulties encountered during the set-up and recruitment phases of these trials, related to gaining the necessary ethical and governance approvals and applying for NHS costs to undertake and deliver the research.
Empirical evidence about delays and difficulties related to regulation and governance of medical research was gathered during the period 2009–2010 from three UK randomised controlled trials with sites in England, Wales and Scotland (1. SAFER 2- an emergency care based trial of a protocol for paramedics to refer patients directly to community based falls services; 2. COnStRUCT- a trial of two drugs for acute ulcerative colitis; and 3. Family Links - a trial of a public health intervention, a 10 week community based parenting programme). Findings and recommendations were reported in response to a call for evidence from The Academy of Medical Sciences regarding difficulties encountered in conducting medical research arising from R&D governance and regulation, to inform national policy.
Difficulties and delays in navigating and gaining the appropriate approvals and NHS costs required to undertake the research were encountered in all three trials, at various points in the bureaucratic processes of ethical and research and information governance approvals. Conduct of each of the three trials was delayed by at least 12 months, with costs increasing by 30 – 40%.
Whilst the three trials encountered a variety of challenges, there were common issues. The processes for gaining approvals were overly complex and differed between sites and UK countries; guidance about processes was unclear; and information regarding how to define and claim NHS costs for undertaking the research was inconsistent. The competitive advantage of a publicly funded, open access health system for undertaking health services research and clinical trials within the UK has been outweighed in recent years by stifling bureaucratic structures and processes for governance of research. The recommendations of the Academy of Medical Sciences are welcomed, and the effects of their implementation are awaited with interest.
Trial Registration numbers
SAFER 2: ISRCTN 60481756; COnStRUCT: ISRCTN22663589; Family Links: ISRCTN 13929732
This paper offers a wide ranging analysis of the drivers that resulted in scrutiny of medical, nursing, and healthcare professional roles. It suggests that what is needed is a coherent vision of the future shape of the health workforce. This requires moving beyond the presumption that reforming working practices primarily involves "delegating doctors" responsibilities to nurses. The paper argues that it is self evident that the implications of changes in healthcare roles and the ability of existing professionals to function effectively in the future will require education, training, and human resource investment supportive of the changes. It suggests a clear definition of competence and a national standard to practice is essential for nurses working in acute and acute critical settings. There should therefore be a correlation between levels of practice, levels of education, and remuneration. Furthermore, education programmes for senior nurses should sit coherently alongside the education programmes required by Modernising Medical Careers. Finally, the realisation of the government's service and modernisation agenda will require a culture change within higher education institutions, postgraduate deaneries, professional organisations, workforce development confederations, and NHS trusts.
Brazil and Colombia have pursued extensive reforms of their health care systems in the last couple of decades. The purported goals of such reforms were to improve access, increase efficiency and reduce health inequities. Notwithstanding their common goals, each country sought a very different pathway to achieve them. While Brazil attempted to reestablish a greater level of State control through a public national health system, Colombia embraced market competition under an employer-based social insurance scheme. This work thus aims to shed some light onto why they pursued divergent strategies and what that has meant in terms of health outcomes.
A critical review of the literature concerning equity frameworks, as well as the health care reforms in Brazil and Colombia was conducted. Then, the shortfall inequality values of crude mortality rate, infant mortality rate, under-five mortality rate, and life expectancy for the period 1960-2005 were calculated for both countries. Subsequently, bivariate and multivariate linear regression analyses were performed and controlled for possibly confounding factors.
When controlling for the underlying historical time trend, both countries appear to have experienced a deceleration of the pace of improvements in the years following the reforms, for all the variables analyzed. In the case of Colombia, some of the previous gains in under-five mortality rate and crude mortality rate were, in fact, reversed.
Neither reform seems to have had a decisive positive impact on the health outcomes analyzed for the defined time period of this research. This, in turn, may be a consequence of both internal characteristics of the respective reforms and external factors beyond the direct control of health reformers. Among the internal characteristics: underfunding, unbridled decentralization and inequitable access to care seem to have been the main constraints. Conversely, international economic adversities, high levels of rural and urban violence, along with entrenched income inequalities seem to have accounted for the highest burden among external factors.
Brazil; Colombia; health care reform; health care system; equity; health inequities; comparative analysis; health policy
To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the “silver tsunami” of 80 million Americans retiring over the next 20 years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.
primary care; workforce; health reform; health policy
Part I (Can J Plast Surg 2000;8:25–29) established that standards of professional practice shift constantly. When a standard falls short of professional expectation or when a physician becomes more concerned with financial gain rather than patient care, society needs the action of a reformer. Parts I, II (Can J Plast Surg 2001;9:59–68) and III (Can J Plast Surg 2002;10:103–108) covered 500 BC to 1970 AD and comprised 31 physicians who introduced innovations in medical knowledge or medical philosophy. Part IV deals with a time in which new conditions have been imposed on medical practice. In the United States, medical education and practice felt the repercussions of financial institutions participating in health care management.
The reformers were scientists who conformed to our definition of ‘reformer’: a person whose action restored, reshaped or advanced the structure or ideology of medical practice.
This survey demonstrated that the reforms were accomplished by scientists possessing critical judgement and analytical qualities that enabled them to influence the direction of medical education and practice. In the last 20 years, financial institutions imposed different criteria that may require future reformers to reestablish lost objectives.
Reforms have been achieved through intuitive leaps, alterations of conventional practice, painstaking research or administrative restructuring. The present health management in the United States requires new solutions.
Historical perspective; Managed Care; Medical reformers
The purpose of this paper is to provide an historical review of the progression of events within the jurisdiction of the province of Ontario related to the issue of laboratory diagnosis and the profession of chiropractic. The provisions of relevant legislation, task forces, Councils, reviews, consensus statements, Commissions and committees, are highlighted and discussed during respective time periods. Chiropractors had entitlement to order and perform laboratory tests until 1972 when a regulatory amendment, made without consultation with the chiropractic profession, precluded their continuing entitlement. Chiropractic patients require access to diagnostic laboratory services and equitable access to necessary laboratory services should be restored and preserved. This is consistent with the academic institutional accreditation standards of chiropractic education and the jurisdictional regulatory mechanisms of chiropractic practice and is consistent with both protecting and enhancing the public interest.
chiropractic; manipulation; legislation; laboratory; diagnosis
Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improving individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient’s personal physician coordinating care throughout a patient’s lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery. Mixed methodology provides greater insight into the unexpressed health needs of individuals and into the creation of delivery systems more likely to achieve the triple aim. In a small, midwestern town, a mixed methods approach was used to assess community health needs to facilitate design and implementation of care delivery systems. The research findings suggest that health system design concepts should focus on the creation of health, not health care; foster simplicity; create nurturing relationships; eliminate user fear; and contain costs. These observations can be helpful to health care professionals who are developing new methods of care delivery and policymakers and payers contemplating new payment systems to achieve the goals of the triple aim.
California's drastic Medi-Cal reforms have created great difficulties in health care for the poor. Patients' clinical problems seldom are apparent in descriptions of changes in public insurance programs. Rapidly escalating costs of Medi-Cal led to irresistible pressures for reform, especially from the business community. The new Medi-Cal regulations provide for prospective contracts with hospitals for inpatient services, the transfer of “Medically Indigent Adults” to the responsibility of county governments and various other straightforward funding cutbacks. Confusion, disruption of services and adverse health outcomes have accompanied the Medi-Cal reforms.
In Bangladesh, widespread dissatisfaction with government health services did not improve during the Health and Population Sector Programme (HPSP) reforms from 1998-2003. A 2003 national household survey documented public and health service users' views and experience. Attitudes and behaviour of health workers are central to quality of health services. To investigate whether the views of health workers influenced the reforms, we surveyed local health workers and held evidence-based discussions with local service managers and professional bodies.
Some 1866 government health workers in facilities serving the household survey clusters completed a questionnaire about their views, experience, and problems as workers. Field teams discussed the findings from the household and health workers' surveys with local health service managers in five upazilas (administrative sub-districts) and with the Bangladesh Medical Association (BMA) and Bangladesh Nurses Association (BNA).
Nearly one half of the health workers (45%) reported difficulties fulfilling their duties, especially doctors, women, and younger workers. They cited inadequate supplies and infrastructure, bad behaviour of patients, and administrative problems. Many, especially doctors (74%), considered they were badly treated as employees. Nearly all said lack of medicines in government facilities was due to inadequate supply, not improved during the HPSP. Two thirds of doctors and nurses complained of bad behaviour of patients. A quarter of respondents thought quality of service had improved as a result of the HPSP.
Local service managers and the BMA and BNA accepted patients had negative views and experiences, blaming inadequate resources, high patient loads, and patients' unrealistic expectations. They said doctors and nurses were demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care. The BMA considered it would be dangerous to attempt to train and register unqualified practitioners.
The continuing dissatisfaction of health workers may have undermined the effectiveness of the HPSP. Presenting the views of the public and service users to health managers helped to focus discussions about quality of services. It is important to involve health workers in health services reforms.
Malaria control in India has occupied high priority in health sector consuming major resources of the Central and State governments. Several new initiatives were launched from time to time supported by foreign aids but malaria situation has remained static and worsened in years of good rainfall. At times malaria relented temporarily but returned with vengeance at the local, regional and national level, becoming more resilient by acquiring resistance in the vectors and the parasites. National developments to improve the economy, without health impact assessment, have had adverse consequences by providing enormous breeding grounds for the vectors that have become refractory to interventions. As a result, malaria prospers and its control is in dilemma, as finding additional resources is becoming difficult with the ongoing financial crisis. Endemic countries must contribute to make up the needed resources, if malaria is to be contained. Malaria control requires long term planning, one that will reduce receptivity and vulnerability, and uninterrupted financial support for sustained interventions. While this seems to be a far cry, the environment is becoming more receptive for vectors, and epidemics visit the country diverting major resources in their containment, e.g. malaria, dengue and dengue haemorrhagic fevers, and Chikungunya virus infection. In the last six decades malaria has taken deep roots and diversified into various ecotypes, the control of these ecotypes requires local knowledge about the vectors and the parasites. In this review we outline the historical account of malaria and methods of control that have lifted the national economy in many countries. While battles against malaria should continue at the local level, there is a need for large scale environmental improvement. Global Fund for AIDS, Tuberculosis and Malaria has provided huge funds for malaria control worldwide touching US$ 2 billion in 2011. Unfortunately it is likely to decline to US$ 1.5 billion in the coming years against the annual requirement of US$ 5 billion. While appreciating the foreign assistance, we wish to highlight the fact that unless we have internal strength of resources and manpower, sustained battles against malaria may face serious problems in achieving the final goal of malaria elimination.
Drug resistance; malaria elimination; malaria profile; malaria vectors; MDG; MPO; urban malaria scheme
Uganda is proposing introduction of the National Health Insurance scheme (NHIS) in a phased manner with the view to obtaining additional funding for the health sector and promoting financial risk protection. In this paper, we have assessed the proposed NHIS from an equity perspective, exploring the extent to which NHIS would improve existing disparities in the health sector.
We reviewed the proposed design and other relevant documents that enhanced our understanding of contextual issues. We used the Kutzin and fair financing frameworks to critically assess the impact of NHIS on overall equity in financing in Uganda.
The introduction of NHIS is being proposed against the backdrop of inequalities in the distribution of health system inputs between rural and urban areas, different levels of care and geographic areas. In this assessment, we find that gradual implementation of NHIS will result in low coverage initially, which might pose a challenge for effective management of the scheme. The process for accreditation of service providers during the first phase is not explicit on how it will ensure that a two-tier service provision arrangement does not emerge to cater for different types of patients. If the proposed fee-for-service mechanism of reimbursing providers is pursued, utilisation patterns will determine how resources are allocated. This implies that equity in resource allocation will be determined by the distribution of accredited providers, and checks put in place to prohibit frivolous use. The current design does not explicitly mention how these two issues will be tackled. Lastly, there is no clarity on how the NHIS will fit into, and integrate within existing financing mechanisms.
Under the current NHIS design, the initial low coverage in the first years will inhibit optimal achievement of the important equity characteristics of pooling, cross-subsidisation and financial protection. Depending on the distribution of accredited providers and utilisation patterns, the NHIS could worsen existing disparities in access to services, given the fee-for-service reimbursement mechanisms currently proposed. Lastly, if equity in financing and resource allocation are not explicit objectives of the NHIS, it might inadvertently worsen the existing disparities in service provision.
In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).
This paper uses data from the National Health Services Surveys of 1998 and 2003 to examine the impact of the reform on population coverage. Particular attention is paid to coverage in terms of gender, age, employment status, and income levels. Following a description of the data between the two years, the paper will discuss the relationship between the insurance reform and the growing inequities in population coverage.
An examination of the data reveals a number of key points:
a) The overall coverage of the newly established scheme has decreased from 1998 to 2003.
b) The proportion of the urban population without any type of health insurance arrangement remained almost the same between 1998 and 2003 in spite of the aim of the 1997 reform to increase the population coverage.
c) Higher levels of participation in mainstream insurance schemes (i.e. GIS-LIS and BHIS) were identified among older age groups, males and high income groups. In some cases, the inequities in the system are increasing.
d) There has been an increase in coverage of the urban population by non-mainstream health insurance schemes, including non-commercial and commercial ones.
The paper discusses three important issues in relation to urban insurance coverage: institutional diversity in the forms of insurance, labour force policy and the non-mainstream forms of commercial and non-commercial forms of insurance.
The paper concludes that the huge economic development and expansion has not resulted in a reduced disparity in health insurance coverage, and that limited cross-group subsidy and regional inequality is possible. Unless effective measures are taken, vulnerable groups such as women, low income groups, employees based on short-term contracts and rural-urban migrant workers may well be left out of sharing the social and economic development.
In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.
Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.
The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.
The government of China promulgated new medical care reform policies in March 2009. After that, provincial-level governments launched new medical care reform which focusing on local comprehensive medical care reform (LCMR). Anhui Province is an example of an area affected by LCMR, in which the LCMR was started in October 2009 and implemented in June 2010. The objective of this study was to compare the job satisfaction (JS) of community health workers (CHWs) before and after the reform in Anhui Province.
A baseline survey was carried out among 813 community health workers (CHWs) of 57 community health centers (CHCs) (response rate: 94.1%) and an effect evaluation survey among 536 CHWs of 30 CHCs (response rate: 92.3%) in 2009 and 2012 respectively. A self-completion questionnaire was used to assess the JS of the CHWs (by the job satisfaction scale, JSS).
The average scores of total JS and satisfaction with pay, contingent rewards, operating procedures and communication in the effect evaluation survey were statistically significantly higher than those of the baseline survey (P<0.05). The average score of satisfaction with promotion (2.55±1.008) in the effect evaluation survey was statistically significantly lower than that in the baseline survey (2.71±0.730) (P=0.002). In both surveys, the average scores of satisfaction with pay, benefits and promotion were statistically significantly lower than the others (all P<0.05).
After two years’ implementation of the LCMR, CHWs’ total JS have a small improvement. However, CHWs have lower satisfaction in the dimensions of pay, promotion and benefits dimensions before and after the LCMR. Therefore, policy-makers should take corresponding measures to raise work reward of CHWs and pay more attention to CHWs’ professional development to further increase their JS.
Human resources are the most important assets of any health system, and health workforce problems have for decades limited the efficiency and quality of Latin America health systems. World Bank-led reforms aimed at increasing equity, efficiency, quality of care and user satisfaction did not attempt to resolve the human resources problems that had been identified in multiple health sector assessments. However, the two most important reform policies – decentralization and privatization – have had a negative impact on the conditions of employment and prompted opposition from organized professionals and unions. In several countries of the region, the workforce became the most important obstacle to successful reform.
This article is based on fieldwork and a review of the literature. It discusses the reasons that led health workers to oppose reform; the institutional and legal constraints to implementing reform as originally designed; the mismatch between the types of personnel needed for reform and the availability of professionals; the deficiencies of the reform implementation process; and the regulatory weaknesses of the region.
The discussion presents workforce strategies that the reforms could have included to achieve the intended goals, and the need to take into account the values and political realities of the countries. The authors suggest that autochthonous solutions are more likely to succeed than solutions imported from the outside.
Since 1960, numerous concepts of health-care reform have been submitted to the US Congress and the American public with different viewpoints and objectives. The priority for the US Congress to pass a bipartisan health-reform plan has been circumvented by the newly elected majority Republican Congress. Nevertheless, health-care cost containment, quality control, and health-care delivery concepts have been implemented gradually into the concept of competitive managerial health care. A few of the serious problems in the African-American community are the efficiency and quality of the health-care delivery system and the effects of managed care on African-American primary physicians and surgical specialists. The critical shortages of this group, especially the latter, may create a dilemma in the implementation of a quality surgical care delivery system. The Association of American Medical Colleges, the American College of Surgeons, and other affiliating organizations should become sensitized to the African-American community's health needs, deficiencies, and the rational institution of an equitable, efficient, comprehensive, and quality health-care plan coupled with a sustained and increasing supply of certified, diversified, and experienced African-American surgical manpower in company with family practice physicians and primary care physicians.
Improving education in health promotion and prevention has been identified as a priority for all accredited professional health care training programs, an issue recently addressed by a collaboration of stakeholders in chiropractic education who developed a model course outline for public health education. Using a course evaluation questionnaire, the authors surveyed students in the public health course at the Canadian Memorial Chiropractic College (CMCC) before and after the implementation of new course content based on the model course outline. Following the new course, there were significant improvements in perceived relevance to chiropractic practice and motivation to learn the material as a foundation for clinical practice. Changes made to the content and delivery of the course based on the model course outline were well received in the short term.
chiropractic; education; public health
Governments in Ontario have promised family physicians (FPs) that participation in primary care reform would be financially as well as professionally rewarding. We compared work satisfaction, incomes and work patterns of FPs practising in different models to determine whether the predicted benefits to physicians really materialized. Study participants included 332 FPs in Ontario practising in five models of care. The study combined self-reported survey data with administrative data from ICES and income data from the Canada Revenue Agency. FPs working in non–fee-for-service (FFS) models had higher levels of work satisfaction than those in FFS models. Incomes were similar across groups prior to the advent of primary care reform. Incomes of family health network FPs rose by about 30%, while family health group FPs saw increases of about 10% and those in FFS experienced minimal changes or decreases. Self-reported change in income was not reliable, with only 47% of physicians correctly identifying whether their income remained stable, increased or decreased. The availability of a variety of FFS- and non–FFS-based payment options, each designed to accommodate physicians with different types or styles of practice, may be a useful tool for governments as they grapple with issues of physician recruitment and retention.
When a disaster occurs, it is for governments to provide the leadership, civil defense, security, evacuation, and public welfare. The medical aspects of a disaster account for less than 10% of resource and personnel expenditure. Hospitals and health care provider teams respond to unexpected occurrences such as explosions, earthquakes, floods, fires, war, or the outbreak of an infectious epidemic. In some geographic locations where natural disasters are common, such as earthquakes in Japan, such disaster practice drills are common. In other locations, disaster drills become pro forma and have no similarity to real or even projected and predicted disasters. The World Trade Center disaster on 11 September 2001 provides new information, and points out new threats, new information systems, new communication opportunities, and new detection methodologies. It is time for leaders of medicine to re-examine their approaches to disaster preparedness.
bioterrorism; detection; disaster planning; terrorism
Little is known about African-American physicians' health system experience or their opinions on health reform. In an attempt to obtain socioculturally relevant data quantifying these experiences and opinions, the National Medical Association administered a 38-question, 80-item survey instrument in August 1993. The questionnaire was completed by 236 physicians. The results indicate that African-American physicians feel health care is a right and that the health system needs fundamental change. Although there was no consensus on the type of health reform needed, approximately 35% cited availability and access to care to be the greatest problem facing the system with high costs of care (18.2%) ranking second. Unique findings in the survey indicated respondents felt that the needs and concerns of most African Americans will not be fairly addressed in the reform of the health-care system, that African-African physicians are not included in the formation of health-care policies, and that African-American physicians are facing high levels of professional and healthcare system racial discrimination. More than 99% of African-American physicians reported some degree of racial discrimination in the practice of medicine including peer review, obtaining practice privileges at hospitals, hospital staff promotions, Medicaid and Medicare reimbursements, malpractice suits, private insurance oversight and reimbursements, and referral practices of white colleagues. These findings have profound health policy, health financing, and health service delivery implications and should be included in debates and deliberations on health reform.
New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).
Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:
1. Loss of autonomy
2. Inadequate management funding and support
3. Inconsistency and variations in contracting processes
4. Lack of publicity and advice around enrolment issues
5. Workforce and workload issues
6. Financial risks
On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.
The key lessons concern:
• the need for a national primary health care strategy
• active engagement of general practitioners and their professional organisations
• recognition of implementation costs
• the need for infrastructural support, including information technology and quality systems
• robust management and governance arrangements
• issues related to critical mass and population/distance trade offs in service delivery models
This special issue addresses the legacy of the United States Public Health Service Syphilis Study on health reform, particularly the Affordable Care Act (ACA). The 12 manuscripts cover the history and current practices of ethical abuses affecting American Indians, Latinos, Asian Americans and African Americans in the United States and in one case, internationally. Commentaries and essays include the voice of a daughter of one of the study participants in which we learn of the stigma and maltreatment some of the families experienced and how the study has impacted generations within the families. Consideration is given in one essay to utilizing narrative storytelling with the families to help promote healing.
This article provides the reader a roadmap to the themes that emerged from the collection of articles. These themes include population versus individual consent issues, need for better government oversight in research and health care, the need for overhauling our bioethics training to develop a population level, culturally driven approach to research bioethics. The articles challenge and inform us that some of our assumptions about how the consent process best works to protect racial/ethnic minorities may be merely assumptions and not proven facts. Articles challenge the belief that low participation rates seen in biomedical studies have resulted from the legacy of the USPHS Syphilis Study rather than a confluence of factors rooted in racism, bias and negative treatment. Articles in this special issue challenge the “cultural paranoia” of mistrust and provide insights into how the distrust may serve to lengthen rather than shorten the lives of racial/ethnic minorities who have been used as guinea pigs on more than one occasion. We hope that the guidance offered on the importance of developing a new framework to bioethics can be integrated into the foundation of health care reform.
Tuskegee; research bioethics; survivors
A comparison of the job satisfaction of health care professionals has not been well studied in Malaysia. This study aimed to compare the job satisfaction level among 8 groups of health care professionals in private settings, using the Job Satisfaction Survey (JSS).
A total of 81 health care professionals, including nurses, physiotherapists, occupational therapists, medical laboratory technologists, dieticians, medical imaging practitioners, environmental health officers, and optometrists in private (non-government) settings in the Klang Valley, were interviewed using the Job Satisfaction Survey scale invented by Dr Paul E Spector. Their job satisfaction scores were calculated and determined.
In the demographic data, the majority of the subjects were 20–30 years old (81.5%), were female (72.8%), had a basic degree (98.8%), were single (64.2%), and had 1–5 years of working experience (83.9%). A Kruskal–Wallis analysis showed significant differences (P < 0.05) in promotion, supervision, operating conditions, co-workers, nature of the work, and communication, but there were no significant differences (P > 0.05) in pay, fringe benefits, and contingent rewards in JSS score among the 8 health care professions. The Friedman Test showed a significant difference of overall JSS scores (χ2 = 526.418, P < 0.001) among the 8 health care professions.
The overall job satisfaction levels are different among health care professionals in private settings, especially regarding promotion, supervision, operating conditions, co-workers, the nature of the work, and communication.
job satisfaction; health care; non-governmental organizations; private sector
China’s healthcare system is experiencing significant growth from expanded government-backed insurance, greater public-sector spending on hospitals, and the introduction of private insurance and for-profit clinics. An incremental reform process has sought to develop market incentives for medical innovation and liberalize physician compensation and hospital finance while continuing to keep basic care affordable to a large population that pays for many components of care out-of-pocket. Additional changes presently under consideration by policymakers are likely to further restructure insurance and the delivery of care and will alter competitive dynamics in major healthcare industries, notably pharmaceuticals, medical devices, and diagnostic testing. This article describes the institutional history of China’s healthcare system and identifies dilemmas emerging as the country negotiates divisions between public and private in healthcare. Building on this analysis, the article considers opportunities for public-private partnerships and greater systems integration to reconcile otherwise incommensurable approaches to rewarding innovation and improving access. The article concludes with observations on the public function of health insurance and its significance to further development of China’s healthcare system.
China; Healthcare reform; Clinical trials; Electronic medical records; Insurance; Pharmaceuticals