Health governance in India: citizenship as situated practice.

Despite the impressive growth of the Indian economy over the past decades, the country struggles to deal with multiple and overlapping forms of inequality. One of the Indian government's main policy responses to this situation has been an increasing engagement with the 'rights regime', witnessed by the formulation of a plethora of rights-based laws as policy instruments. Important among these are the National Rural Health Mission (NRHM). Grounded in ethnographic research in Rajasthan focused on the management of maternal and child health under NRHM, this paper demonstrates how women, as mothers and health workers, organise themselves in relation to rights and identities. I argue that the rights of citizenship are not solely contingent upon the existence of legally guaranteed rights but also significantly on the social conditions that make their effective exercise possible. This implies that while citizenship is in one sense a membership status that entails a package of rights, duties, and obligations as well as equality, justice, and autonomy, its development and nature can only be understood through a careful consideration and analysis of contextually specific social conditions.

Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010.

INTRODUCTION: The true prevalence of gestational diabetes mellitus (GDM) is unknown. The objective of this study was 1) to provide the most current GDM prevalence reported on the birth certificate and the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and 2) to compare GDM prevalence from PRAMS across 2007-2008 and 2009-2010. METHODS: We examined 2010 GDM prevalence reported on birth certificate or PRAMS questionnaire and concordance between the sources. We included 16 states that adopted the 2003 revised birth certificate. We also examined trends from 2007 through 2010 and included 21 states that participated in PRAMS for all 4 years. We combined GDM prevalence across 2-year intervals and conducted t tests to examine differences. Data were weighted to represent all women delivering live births in each state. RESULTS: GDM prevalence in 2010 was 4.6% as reported on the birth certificate, 8.7% as reported on the PRAMS questionnaire, and 9.2% as reported on either the birth certificate or questionnaire. The agreement between sources was 94.1% (percent positive agreement = 3.7%, percent negative agreement = 90.4%). There was no significant difference in GDM prevalence between 2007-2008 (8.1%) and 2009-2010 (8.5%, P = .15). CONCLUSION: Our results indicate that GDM prevalence is as high as 9.2% and is more likely to be reported on the PRAMS questionnaire than the birth certificate. We found no statistical difference in GDM prevalence between the 2 phases. Further studies are needed to understand discrepancies in reporting GDM by data source.

Financial viability of perinatal centers in the longer term, taking legislative requirements into account. An examination of the cost-revenue structure of a Level I perinatal center.

BACKGROUND: Debate is currently taking place over minimum case numbers for the care of premature infants and neonates in Germany. As a result of the Federal Joint Committee (Gemeinsamer Bundesauschuss, G-BA) guidelines for the quality of structures, processes, and results, requiring high levels of staffing resources, Level I perinatal centers are increasingly becoming the focus for health-economics questions, specifically, debating whether Level I structures are financially viable. MATERIALS AND METHODS: Using a multistep contribution margin analysis, the operating results for the Obstetrics Section at the University Perinatal Center of Franconia (Universitäts-Perinatalzentrum Franken) were calculated for the year 2009. Costs arising per diagnosis-related group (DRG) (separated into variable costs and fixed costs) and the corresponding revenue generated were compared for 4,194 in-patients and neonates, as well as for 3,126 patients in the outpatient ultrasound and pregnancy clinics. RESULTS: With a positive operating result of € 374,874.81, a Level I perinatal center on the whole initially appears to be financially viable, from the obstetrics point of view (excluding neonatology), with a high bed occupancy rate and a profitable case mix. By contrast, the costs of prenatal diagnostics, with a negative contribution margin II of € 50,313, cannot be covered. A total of 79.4% of DRG case numbers were distributed to five DRGs, all of which were associated with pregnancies and neonates with the lowest risk profiles. CONCLUSION: A Level I perinatal center is currently capable of covering its costs. However, the cost-revenue ratio is fragile due to the high requirements for staffing resources and numerous economic, social, and regional influencing factors.

[Neoliberalism in health: the torture of the health care workers of the Bogota's Instituto Materno Infantil (child and maternity hospital)]. / Neoliberalismo en salud: la tortura de trabajadoras y trabajadores del Instituto Materno Infantil de Bogotá.

OBJECTIVES: To link, from a historical point of view, the most significant transformations of the Instituto Materno Infantil (IMI) [the oldest child and maternity hospital of the country] during its process of crisis, closure and liquidation with the experiences of the hospital workers. To find experience-based and theoretical elements that can interconnect the process of health care privatization of the country with the workers' experiences of resistance and pain/suffering. METHODS: Critically-oriented ethnography based on continuous collective field work, historical research (primary and secondary sources) and semi-structured interviews with 5 women who worked at the IMI for more than 15 years. RESULTS: A time line of 4 main periods: Los años de gloria [The golden years] (up to 1990); Llega el neoliberalismo [Neoliberalism arrives] (1990-2000); La crisis y las resistencias [Crisis and resistances] (2001-2005); and Liquidación [Liquidation (2006-20??)]. The narratives of the interviewed women unveil multiple aggressions that have intensified since 2006, have caused pain and suffering and are examples of violations of human and labour rights. DISCUSSION: We suggest to analyze the links between the different kinds of violence and pain and suffering as torture. This category is defined as the set of violent actions that cause physical and emotional pain, which are performed by actors in positions of power over other people who challenge that power and are part of modern States' ideological principles around a defined moral social order. For the IMI workers' case, the ideological principle that is being challenged is health care neoliberalism. From the analyses of bureaucracy, confinement, torturing agents, and the breaking-off of the body-mind unit we conclude that this relationship between neoliberalism and torture aims to eliminate the last health care workers of the country who had job stability and full-benefits through public labour contracts. Their elimination furthers the accumulation of capital generated by increasing over-exploitation of labour and commodification of health care.

Neoliberalismo en salud: La tortura de trabajadoras y trabajadores del Instituto Materno Infantil de Bogotá / Neoliberalism in health: the torture of the health care workers of the Bogota s Instituto Materno Infantil (child and maternity hospital)

Objetivos Relacionar históricamente las transformaciones más significativas del Instituto Materno Infantil (IMI) en su proceso de crisis, cierre y liquidación con las experiencias de sus trabajadores/as. Encontrar elementos vivenciales y teóricos que interconecten el proceso de privatización de la salud con las experiencias de resistencia y dolor/sufrimiento de trabajadores/as. Métodos Etnografía inscrita en corrientes críticas y apoyada en trabajo de campo constante y colectivo, investigación histórica (fuentes primarias y secundarias) y entrevistas semiestructuradas con cinco mujeres que trabajaron por más de quince años en el IMI. Resultados Una línea del tiempo con cuatro periodos principales: Los años de gloria (hasta 1990), Llega el neoliberalismo (1990-2000), La crisis y las resistencias (2001-2005) y Liquidación (2006-). La narrativa de las mujeres entrevistadas devela múltiples agresiones que se intensificaron desde el 2006 generando dolor/ sufrimiento, relatos que ilustran violaciones a sus derechos humanos y laborales. Discusión Proponemos analizar las conexiones entre los diferentes tipos de violencia y el dolor/sufrimiento bajo la categoría tortura, entendida como acciones violentas que causan dolor físico-emocional, las cuales son ejecutadas por actores de poder sobre otros que desafían alterarlo. Enfatizamos en las burocracias, el confinamiento, los agentes torturadores y los resquebrajamientos a la unidad mente/cuerpo para argumentar que esta relación neoliberalismo y tortura pretende eliminar los últimos trabajadores/as de la salud del país con garantías laborales para avanzar en la acumulación de capital que genera la creciente sobreexplotación del trabajo y la mercantilización de la salud.

Objectives To link, from a historical point of view, the most significant transformations of the Instituto Materno Infantil (IMI) [the oldest child and maternity hospital of the country] during its process of crisis, closure and liquidation with the experiences of the hospital workers. To find experience-based and theoretical elements that can interconnect the process of health care privatization of the country with the workers' experiences of resistance and pain/suffering. Methods Critically-oriented ethnography based on continuous collective field work, historical research (primary and secondary sources) and semi-structured interviews with 5 women who worked at the IMI for more than 15 years.Results: A time line of 4 main periods: Los años de gloria [The golden years] (up to 1990); Llega el neoliberalismo [Neoliberalism arrives] (1990-2000); La crisis y las resistencias [Crisis and resistances] (2001-2005); and Liquidación [Liquidation (2006-20??)]. The narratives of the interviewed women unveil multiple aggressions that have intensified since 2006, have caused pain and suffering and are examples of violations of human and labour rights. Discussion We suggest to analyze the links between the different kinds of violence and pain and suffering as torture. This category is defined as the set of violent actions that cause physical and emotional pain, which are performed by actors in positions of power over other people who challenge that power and are part of modern States' ideological principles around a defined moral social order. For the IMI workers' case, the ideological principle that is being challenged is health care neoliberalism. From the analyses of bureaucracy, confinement, torturing agents, and the breaking-off of the body-mind unit we conclude that this relationship between neoliberalism and torture aims to eliminate the last health care workers of the country who had job stability and full-benefits through public labour contracts. Their elimination furthers the accumulation of capital generated by increasing over-exploitation of labour and commodification of health care.

Access, quality and costs of prenatal diagnosis.

The background risk of birth defects ranges from 2 to 5%. These birth defects are responsible for 30% of all admissions to pediatric hospitals and are responsible for a large proportion of neonatal and infant deaths. Medicine and Genetics have taken giant steps in their ability to detect and treat genetic disorders in utero. Screening tests for prenatal diagnosis should be offered to all pregnant women to assess their risk of having a baby with a birth defect or genetic disorder. Psychosocial and financial factors, inadequate insurance coverage, and the inability to pay for health care services are some of the known barriers to healthcare. These barriers are particularly magnified when there is a language barrier. From an economical standpoint it has been demonstrated that prenatal diagnosis has the potential of saving millions of dollars to our healthcare system. But when patients do not have the resources to access prenatal care and prenatal diagnosis cost shifting occurs, escalating healthcare costs. Our current healthcare system promotes inequalities in its delivery. With the existing barriers to access, quality, and costs of prenatal diagnosis we are confronted with an inefficient and flawed system.

Preventable newborn readmissions since passage of the Newborns' and Mothers' Health Protection Act.

BACKGROUND: Congress passed the Newborns' and Mothers' Health Protection Act in 1996, reversing the trend of shorter newborn nursery lengths of stay. Hope existed that morbidities would lessen for this vulnerable population, but some reports indicate that the timeliness and quality of postdischarge care may have worsened in recent years. OBJECTIVE: Our goal was to determine risk factors for the potentially preventable readmissions because of jaundice, dehydration, or feeding difficulties in the first 10 days of life in Pennsylvania since passage of the Newborns' and Mothers' Health Protection Act. PATIENTS AND METHODS: Birth records from 407,826 newborns > or = 35 weeks' gestation from 1998 to 2002 were merged with clinical discharge records. A total of 2540 newborns rehospitalized for jaundice, dehydration, or feeding difficulties in the first 10 days of life were then compared with 5080 control infants. Predictors of readmission were identified by using multiple logistic regression analysis. RESULTS: An unadjusted comparison of baseline characteristics revealed numerous predictors of readmission. Subsequent adjusted analysis revealed that Asian mothers, those 30 years of age or older, nonsmokers, and first-time mothers were more likely to have a readmitted newborn, as were those with diabetes and pregnancy-induced hypertension. For neonates, female gender and delivery via cesarean section were protective for readmission, whereas vacuum-assisted delivery, gestational age < 37 weeks, and nursery length of stay < 72 hours were predictors of readmission in the first 10 days of life. CONCLUSIONS: Although readmissions for jaundice, dehydration, and feeding difficulties may be less common for some minority groups and Medicaid recipients in the era of the Newborns' and Mothers' Health Protection Act compared with nonminorities or privately insured patients, several predictors of newborn readmission have established associations with inexperienced parenting and/or breastfeeding difficulty. This is one indication that this well-intentioned legislation and current practice may not be sufficiently protecting the health of newborns and suggests that additional support for mothers and newborns during the vulnerable postdelivery period may be indicated.

The role of risk management in maternal-child health.

In today's litigious medical environment, risk managers serve as a support to health care providers by managing potential or actual liability situations. They analyze the facts in an untoward event, help clinicians communicate the appropriate information to the patient and family, and document it in an objective manner. This article briefly describes the inception of the risk managers' role, details how risk managers can provide support to members of the medical and nursing staffs and what their role is in patient safety, and explains various basic legal concepts that are important to understand should litigation ensue following an adverse event.

Managed health care for Medicaid enrollees: the Philadelphia model.

HealthPASS, a program of capitated managed care for 82,000 Medicaid enrollees in a defined geographic area of Philadelphia, Pennsylvania, is administered by Healthcare Management Alternatives, Inc. (HMA), a minority-owned corporation, under a multiyear contract with the Commonwealth of Pennsylvania. HMA has striven to improve care to this low-income community by mounting innovative campaigns to encourage early access to health care, ongoing health education, and aggressive outreach and follow-up, in addition to specific projects designed to reduce infant mortality, expand Head Start, and bolster pediatric care. The program has been judged independently to provide high-quality service cost-effectively.