Category Archives: #GPH2110

COST OF CHANGE

The provision of health as we know now has come a long way. There have been changes in the concept and definition of health as well as the practice of medicine. Health concept and health systems differs in different parts of the world and this is influence by the political ideology of the nation [1]. This informs the health policies and practices [2]. The growth and development of health care services, systems and who benefits form it has come from many contributions: individuals, military services, missionary hospitals and the major player in health care, the government [1]. These agencies along with professional associations, various ministries in the federal and state governments with international agencies will continue to shape health care and bring reforms in the future [1].

The cost of health care services has grown and the insurance companies now play a major role as well as being driven by market forces and international corporations [1]. The future of the types of care available, who can access this care and who bears the cost is gradually being determined by the insurance companies and other nongovernmental agencies such as pharmaceutical companies and makers of medical supplies. Countries with socialist ideology who see health as a right of the citizens make effort to make health care available to all and the government paying for it. Example of this is the United Kingdom with its National Health scheme and Brazil [3]. The tax payers pay the bill. Canada on the other hand has mixed system with private/public partnership but all citizens are covered and have insurance. The United States of America has a great proportion of citizens’ uninsured, some are insured through their employers and others are self-insured. Any changes needed in the health system will take into consideration the financial cost of the innovation. The purchase of new medical equipment is not just a medical and administrative decision but the financial burden determines what the next purchase will be. Treatment regimens which was the prerogatives of doctors and health team is now determined by what the insurance companies are ready to pay for, or approve as a needed protocol.

The final cost is on the patient who cannot get what is the optimum care in the best system from the best care givers. Health reform will come from the active role of government, her policies, international bodies and associations of professional as well as other agencies in the health industry who will see a need for reform and guarantee that needed reforms are carried out without the interference and dictates of health insurance companies even when these are state owned [4].

 

1.            Reich, M.R., Reshaping the state from above, from within, from below: implications for public health. Social Science & Medicine, 2002. 54(11): p. 1669-1675.

2.            Lakin, J.M., The end of insurance? Mexico’s Seguro Popular, 2001–2007. Journal of Health Politics, Policy and Law, 2010. 35(3): p. 313-352.

3.            Arnquist, S., A. Ellner, and R. Weintraub, HIV/AIDS in Brazil: Delivering Prevention in a Decentralized Health System. Cases in Global Health Delivery, 2011. 018: p. 1-31.

4.            Glassman, A., et al., Political analysis of health reform in the Dominican Republic. Health Policy and Planning, 1999. 14(2): p. 115-126.

 

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Decentralization to improve health delivery not merely a byproduct of political changes

Decentralizing the health service delivery provides a unique opportunity to improve health performance at the district level. Decentralization approach includes transferring financial, administrative, ownership, and political authorities for alternate institutions in the peripheral. The rationale for transferring such power is; local decision makers have access to better information on local circumstances than central authorities, thus they have all the legitimacy to modify services, operation, spending pattern as it suits to the local needs and preferences.

In the past, various forms of decentralization have been instituted in many developing nations and the results have not always resulted in an improvement of the health of the national population for many reasons. For instant, in Chile and Mexico, when decentralization of the health sector was implemented, municipal authorities were given decision making power with respect to health including employing health professionals. However, the central government retained economic power over the national health budget, thus the local authorities were unable to address health needs of the their people because they were not able to pay salaries of their workers.[1] On the other hand, when China implemented decentralization in the 1980s, the local public health authorities
 were given full control of health services delivery, however the central government decreased the national provided health budget and imposed user fees and taxes on families for health services.[2] In contrast to the above examples, Cameroon and Brazil’s implementation of decentralization proved to be the best models not only in controlling specific disease, but also in improving health services delivery nationally.[3] One of the noticeable benefits of the decentralization approach was enabling of efficient distribution of antiretroviral treatments to control HIV/AIDS. For example, Cameroon provided medical access to 58% of all eligible HIV/AIDS patients; this is one of the highest treatment rates in Africa.[4]  Brazil once had very high prevalence of HIV/ADIS similar to South Africa, however through the decentralization approach, it was able to stabilize the HIV epidemic to levels resembling those of the United States and Western Europe[5]. The secret to their successful implementation of decentralization was attributed the central government that fully decentralized its national health planning, health financing and community participation programs.

The above examples demonstrate how difficult the implementation of decentralization can get and how easily the system can be manipulated to pursue other political aims. When implementing decentralization, additional reforms such as allocation of financial and qualified personnel must be followed. The focus for decentralization is to make the operation of health facilities efficient, thus routine regional supervision of the health facilities and standardization of drugs and treatment plans should continue until the peripheral administrative are fully capable of handling all the tasks. The national government should continue investing on peripheral health systems and not to pursue other political aims with name of decentralization. If decentralization is implemented correctly, the positive outcomes will include equitable resource allocation between urban and rural areas, improved health service delivery in rural areas, and increase in access to essential medicines.


[1] Khan, S.& Willis, K. (2009) Health Reform in Latin America and Africa: decentralization, participation and inequalities. Third World Quarterly, 30 (5), 991-1005.

[2] Blumenthal, D. & Hsiao, W. (2005). Privatization and its Discontents – The Evolving Chinese Health Care system. New England Journal of Medicine, 353(11), 1165- 1170.

[3] Berman, P.A. & Bossert, T.J. (2000). A Decade of Health Sector Reform in Developing Countries: What Have We Learned? DDM Symposium. DPE-5991-1-A-00-1052-00

[4] Loubiere, S., Boyer, S., Protopopescua, C., Bononod, C.R., Abegad, S., Spirea, B. & Moattia, J.(2009). Decentralization of HIV care in Cameroon: Increased access to antiretroviral treatment and associated persistent barriers. Health Policy, 92(2/3), 165-173.

[5]  Case in global health delivery (2011) “HIV/AIDS in Brazil delivering Prevention in Decentralization Health System” Harvard Medical School.

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Hospital? You mean HoSPAtal.

When I was in undergrad, I took a class on birth and reproduction in various nations. One of the books we had to read for it was “Birth in Four Cultures” by Brigitte Jordan. It followed the labor and delivery of 4 young mothers from Yucatan, Sweden, Holland, and the United States. Since the author is an anthropologist, it was more of a narrative of the different women’s experiences than an analysis of the health systems (although she did include maternal mortality statistics for each country). One thing I came away with after reading this book was that participants in each country found their health system to be superior to others.

Incidentally, my sister had been expecting her first child at this time. She spent part of her pregnancy in India and part of it in the United States. During 2009-2013, India has had an estimated maternal mortality ratio of 200 deaths per every 100,000 live births. The United States, on the other hand, was closer to 21 per 100,000 live births. While we are behind most developed nations, the US is thought of to have a better health care system than the moderately developed India. Despite the drastic difference in rates, my sister said she felt her prenatal treatment was actually of better quality in India. I found that strange until she told me about (in her words) “The best hospital spa she had ever been to in her life.”  Yes, a hospital SPA. You see, my sister was in India just as the newest franchise in a chain of luxury prenatal hospitals had opened up in her city. Known as the Cradle (Makes you feel all warm and fuzzy, doesn’t it?), this facility calls itself as a “50 bed boutique surgical center” and boasts “5-star hotel amenities”. If you go to the website, you’ll enter a world of pastel, flowers, and fat, healthy Caucasian-looking(?) babies. It makes delivery look like just another treatment to fit in between your mani-pedi and seaweed wrap.

You’re looking at the face of Koramangala.

More like GORA*-mangala. (Oh god that was a terrible pun. Sorry about that.)

Her experience in a public hospital in the US, on the other hand, sounds like a nightmare. With its long waits between appointments, phone tag with insurance companies, and a barely 10 minute visit with her OB asking about her pregnancy highlights before the (understandably over worked) doctor moves on to the next patient inline, my sister was not happy with her American services. And everyone knows to NEVER upset a pregnant woman. The Cradle and my sister’s US experience may not be an accurate representation of prenatal care in their respective health care systems. The US can have equally swanky private birthing suites for high income clientele and India still has to develop solutions for a litany of obstacles that prevent some mothers from having safe deliveries. However, the privatization of maternal health in India has provided high income parents-to-be a niche outside of the national health care system where they can get the most bang for their buck. Google “maternity hospital” with  *insert medium to large Indian city here* and you’ll find several chains of high comfort maternity hospitals popping up all around the country. Before you go off raging against capitalism and the unfairness of life for low-income women, there is a silver lighting. Franchised hospitals for low-income women have also been opening up in the same region. While this might still be too expensive for some of the poorest women, it shows a trend of businesses providing services for disenfranchised populations outside of a health care system that doesn’t always succeed in the same tasks. So before you go off saying how “our health care system is better than yours” no matter what side of the world you live on, be aware that there will always be super rich people who have it better off than you. Yay?

P.S. I kind of want a mani-pedi (minus the baby) now.

*Hindi-Urdu for light skinned.

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1-800-gonna-be-dead-soon

understanding-insurance-large

It was one of those rare moments where I sat down one evening and attempted to watch Sunday football. During the commercial break, I was changing the channels absent-mindedly dreading the Monday ahead but then something caught my attention. An infomercial channel dedicated for health insurance shopping at the convenience of your home. Yes, you heard it call 1-800-gonna-be-dead-soon! What was even scarier than the channel itself were the ages of the people who were doing the testimonials; almost everybody was an AARP member. It made me wonder, “Do we only need to see a doctor when we are 65 or older?”

The US spends outrageous amounts of money on healthcare per capita about $US 7,583. Notwithstanding, 47 million of Americans (about 42% of adults) still remain uninsured or underinsured. The US is the only developed nation with no universal health coverage for its citizens (Brin et al, 2009). If we look at another country, say, the UK, health system is provided by the National Health Services. It is a comprehensive health care system that includes primary health care as well as a dental plan and prescription drugs coverage. It is funded by central taxation and the country tries hard to protect its citizens from out-of-pocket medical expenses. The UK spends about US $3,129 per capita on health insurance and this amount is almost half of what the US spends per capita (Schoen et al, 2010).

No one denies that it can be challenging to evaluate the health outcomes of different health systems. However, an influential study published in 2012 by Mckee and Nolte attempted to use amenable mortality as a parameter to assess health services. Amenable mortality is an index for health quality. It includes a list of conditions that people should not die from if interventions were accessed in a timely and effective manner. Some preventable conditions included were diabetes, appendicitis, and simple infections. This study compared the US to the UK, France and Germany. Between 1999-2007, amenable mortality fell by 36.9 % for men in the UK with only 18.5% decrease in the US. In the same study, the US recorded the highest rate of amenable mortality, which was nearly twice as much as that of France. This is not to say that the US has not made progress in health outcomes over the past decade, however, the rate of process does not commensurate with the amount of money spent on healthcare (Nolte and Mckee, 2012).

The US continues to pioneer medical research, innovation, and state-of-the art medial procedures, yet it fails to provide adequate primary healthcare coverage for all Americans. Shopping for health insurance on TV in a country that dominates the free market system goes beyond our expectations and indeed appears ludicrous to outsiders. Critics have attributed this weak health system coverage to two factors: the poor are not represented enough to lobby for coverage and the limited role of the government (Schroeder, 2007).

Obamacare seems promising. Well, don’t we all agree that minimum healthcare coverage is better than nothing? Many critics are taking Obamacare with a grain of salt saying it’s ‘messy.’ According to the New York Times, Families USA (an advocate organization for Obamacare) estimated that last year an American dies every 20 minutes because they didn’t have health insurance. The Obamacare offers the opportunity for many young Americans to have health insurance and access to medical care and preventive medicine. This is not only beneficial to the health of the population but also to the US economy in the long run. It has the potential to save millions of dollars on preventable diseases. It might take some time to achieve the goal of universal healthcare coverage for all Americans. However, Obamacare might be the light at the end of the tunnel if it worked the way it intended to.

Anne-Emanuelle Brin, Yogan Pillay, Timothy H. Holtz. Text Book of International Health: Global Health in a Dynamic World, 3rd edition. 2009. Oxford University Press New York, NY.

Cathy Schoen, Robin Osborn, David Squires, Michelle M. Doty, Roz Pierson and Sandra Applebaum. How Health Insurance Design Affects Access To Care And Costs, By Income, In Eleven Countries. Health Affairs, 29, no.12 (2010):2323-2334

 

Ellen Nolte and C. Martin McKee. In Amenable Mortality–Deaths Avoidable Through Health Care–Progress In The US Lags That Of Three European Countries Health Affairs, , no. (2012): published online August 29, 2012; 10.1377/hlthaff.2011.0851)

 

Nicholas Kristof. This Is Why We Need Obamacare. Access online on November 5th, 2013. http://www.nytimes.com/2013/11/03/opinion/sunday/kristof-this-is-why-we-need-obamacare.html?adxnnl=1&adxnnlx=1384127406-JRwOhNoqcMGD+ChwLjRG3Q&_r=0

Schroeder, S. We Can do better-improving the health of the American people. N Engl J Med 2007;357:1221-8.

 

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Uncle!!

There’s a lot of arm twisting going on in international health policy.  It reminds me of the crude sibling games I played with my brothers trying to see who will throw in the towel first……”UNCLE! I give up.”  Attempts at national health reforms under the best of circumstances is quite a challenge but in the uncontrolled political and social environments that often exist in some developing countries, the task is formidable.  Many nations are buffeted from all sides by forces within, without, and a third somewhere in between.

Many of these forces are external, highly organized, and well-funded international well-wishers and well-intended aid agencies and NGO’s as well as opportunistic multi-national companies single-mindedly focused on further increasing their coffers at the expense of hosting nations.  They all come with strings attached:  some are attached to purses that only open with the state’s surrender to the will of the owner of the purse; others are attached to threats of abandonment if one fails to comply.  Few seem to take stock of the medium and long-term impacts of their ‘help,’  while some seem to find their voices in complaining about the ‘cycle of dependency’ of developing countries and the ‘slowness of progress and change’ as if all these happen in a vacuum, away from the active participation of these players.

But hold up!  These nations are not themselves blameless victims, they have their own ‘home-grown’ forces, from the rotund political and entrepreneurial plutocrats who put personal gain above national good or benefit, to the home-inspired NGO’s wielding their limited influence for their own private agendas, failing to see ‘the forest for the trees,’ to even the ‘powerless’ masses who fail to realize their true power and neglect to acquire the greatest of all power: information and knowledge; resigning, instead, to distrust the ‘System’ that IS truly broken and pining for the Western green pastures of ‘marketization’ with its promise of ‘economic freedom’ and ‘tide-riding boats’ to the land of riches.   Look out, there are yet unforeseen icebergs ahead!

Ok, so there’s enough blame to go around…but is it wise or even useful to dwell on such things?  Here’s the reality.  Change is hard but necessary.  It requires sustained effort and HARD WORK and it’s only brought about by you.  Yes, YOU.  What will you need?  Information.  Organization.  A reality check; context, both socially and politically, because you are going to need the help of the players mentioned above: you know, the ‘well-wishers’ and ‘plutocrats’ too.  Learn to schmooze; be politically savvy.  Also, know your stuff; be technically correct, equipped with the evidence you will need to both sell your point and ultimately make your point; accomplishing the reforms you seek.  See?  No, sweat, now get to work!

References:

  1. Reich, MR. (2002) “Reshaping the state from above, from within, from below: implications for public health.”  Social Science and Medicine.  54(11):1669-75.
  2. Glassman, A. (1999) “Political analysis of health reform in the Dominican Republic.”  Health Policy Plan.  23(2):150-60.

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Humiliation for Hungary

Dinosaur doesn't speak Hungarian

Dinosaur doesn’t speak Hungarian

Hungary is under international pressure to reform its policies and attitudes regarding domestic violence.  It wasn’t until July 2013 that domestic violence became a crime under Hungary’s penal code but even with increased legal pressure, domestic violence continues to be a huge issue.  Until this time, domestic violence abusers could be charged with battery depending on the severity of the injury sustained by the victim.  Now, victims of domestic violence are able to get restraining orders against their abusers but they are difficult to get.  In a Human Rights Watch report released today, Hungary was criticized for its lack of police response, legal protections, and health support for victims of domestic violence[1].  Not only is it difficult to seek help from law enforcement but when they receive medical attention, doctors often ignore signs of abuse and document injuries incorrectly leaving lawyers out of luck when they attempt to prosecute.  The system that victims find themselves in is the work of policy makers such as István Varga who stated that,  “women should primarily focus on raising children, and we should discuss how families could have three, four or five kids rather than only one or two.  This would help us to honour each other more, and domestic violence would not be an issue…. After helping the country by giving birth to two, three or four children, … women can find and emancipate themselves.[2]”  Domestic violence is not seen as a social or health issue in Hungary which is a huge part of the problem.  If women continue to be seen merely as the producers of children and second-class citizens, it will be a very long time before they are afforded the right of autonomy.

Hungary has faced international pressures before, specifically under the Convention for the Elimination of All Forms of Discrimination Against Women (CEDAW).  In Ms. A.T. v. Hungary, A.T. suffered regular and severe domestic violence at the hands of her husband[3].  A.T. was lucky enough to have her case heard in court but, because protection orders didn’t exist under Hungarian law, her husband was allowed to return to their home.  A.T. and her children were unable to go to a shelter because there were none that could accommodate them, a persistent issue in Hungary.  A.T. brought a claim under CEDAW after exhausting all of her domestic remedies and receiving no relief.  The Committee for CEDAW determined in 2003 that Hungary did not have adequate protections for victims of domestic violence and recommended that Hungary create a national strategy to both prevent and treat violence in the family effectively.  Even after this decision ten years ago, the prevention and treatment of domestic violence has not improved.  News groups such as Aljazeera, Reuters, and FoxNews reran HRW’s report with headlines like, “Report slams domestic abuse in Hungary” just hours after the report was released[4].  Maybe what it will take to generate interest in substantial social, legal, and healthcare reform in Hungary is public humiliation by the international community.


[1] Human Rights Watch “Unless Blood Flows” 2013

http://www.hrw.org/news/2013/11/06/hungary-chronic-domestic-violence

[2] Papageorgiou, Alia. “Hungary’s about turn on domestic violence” New Europe 2012

http://www.neurope.eu/article/hungarys-about-turn-domestic-violence-0

[3] Views on the Committee on the Elimination of Discrimination against Women, Communication No.: 2/2003, Ms. A.T. v. Hungary

http://www2.ohchr.org/english/law/docs/Case2_2003.pdf

[4] Jovanovski, Kristina. “Report slams domestic abuse in Hungary” Aljazeera 2013

http://www.aljazeera.com/indepth/features/2013/11/report-slams-domestic-abuse-hungary-2013116935944883.html

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Access, Expansions, Parity galore!

Promises for Mental Health Reform

MentalHealth-HeadGraphic-250px_1  Mental health care services have always been very limited and continue to dwindle in the USA.  Even with the creation of the Mental Health Parity Act in 2008 there have been many cuts to mental health services.  With 1 out of 4 Americans to have an experience with mental illness, there is a great need to increase mental health services, not cut them from the state budget.  The stigma that is associated with mental illness and the cost of such care has led to severe cuts in emergency services, inpatient beds, residential programs, therapy and counseling services, and substance abuse programs leading many mentally ill citizens to homelessness, nursing homes, and jails which are not equipped to care for their mental illness.   In order to improve the mental health of our country, health reform efforts have to ensure proper care not only for physical illness but also mental.[1] Providing adequate community services might help to reduce and prevent ER visits and hospitalizations that are costly.

As of now there are 11 million people living with mental illness that are uninsured in the United States.[2]  The Affordable Care Act (ACA) has promised to expand the parity act to ensure that mental health and substance abuse services are delivered to those who need them.  The expansion and new reforms look very promising:

  • For those not insured, coverage through marketplaces will be more easily accessible
  • Insurers cannot deny coverage due to a pre existing condition such as depression or bipolar disorder
  • People will get overall better care through essential benefits packages to focus on the continuum of care, not just specific treatments
  • There can be no lifetime limit on mental health care[3]

While these are all great improvements, many of these have not gone into effect yet.  It is hard to tell how successful they will be.  A major concern for those with mental illness is that many will not be covered by these expansions everywhere due to many states’ decision not to expand Medicaid.  Without the Medicaid expansion treatment and care will be very hard to access for those most in need of mental health services.[4]  Only time will tell what the results will be to understand the scope of mental health coverage in the US.  The need for better mental health care is great, so lets cross our fingers!

I end this post with some thought questions:

Will a change in political leaders or a balance of power at the state or federal level influence decisions to expand Medicaid? Will there be new incentives for these states?  How will the coverage play out for those with mental illness in states not expanding?  What will other countries learn from our reform as mental illness becomes a growing burden of disease?

References


[1] Landsberg, G. & Rock, M. (2010) The context of social work practice: Social policy and social work. Learning Solutions: New York.

[2] NAMI. (2013) Health reform and mental health. Issue Brief  Retrieved from: http://www.nami.org/Content/NavigationMenu/Inform_Yourself/About_Public_Policy/Issue_Spotlights/NAMI-FactSheet1_HealthReformMH.pdf

[4] Grohol, G. (2013) An update on how the US Affordable Care Act impacts mental health care.  Retrieved from: http://psychcentral.com/blog/archives/2013/11/01/an-update-on-how-the-u-s-affordable-care-act-impacts-mental-health-care/

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