The German health care Innovation Fund - An incentive for innovations to promote the integration of health care.

PURPOSE: Many health systems face challenges such as rising costs and lacking quality, both of which can be addressed by improving the integration of different health care sectors and professions. The purpose of this viewpoint is to present the German health care Innovation Fund (IF) initiated by the Federal Government to support the development and diffusion of integrated health care. DESIGN/METHODOLOGY/APPROACH: This article describes the design and rationale of the IF in detail and provides first insights into its limitations, acceptance and implementation by relevant stakeholders. FINDINGS: In its first period, the IF offered € 1.2 billion as start-up funding for model implementation and evaluation over a period of four years (2016-2019). This period was recently extended to a second round until 2024, offering € 200 million a year as from 2020. The IF is triggering the support of relevant insurers for the development of new integrated care models. In addition, strict evaluation requirements have led to a large number of health service research projects which assess structural and process improvements and thus enable evidence-based policy decisions. ORIGINALITY/VALUE: This article is the first of its kind to present the German IF to the international readership. The IF is a political initiative through which to foster innovations and promote integrated health care.

The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate.

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.

Financial Crisis in Portugal: Effects in the Health Care Sector.

Portugal has faced an economic and financial crisis that began circa FY2009 and whose effects are still ongoing. In FY2011, the Portuguese state and the European triumvirate - composed of the European Commission, the International Monetary Fund, and the European Central Bank - signed the Memoranda of Understanding. This troika agreement aimed to improve the operational efficiency of public services. This crisis had a considerable impact on the Portuguese citizens' life and productivity, as well as on the public health care system. Cuts over public expenditures have been made to reduce the risk of noncompliance with budgetary targets, despite their potential impact on quality and access to health care services. We analyzed the main policies and measures undertaken by the Portuguese Ministry of Health with respect to the bailout program associated with the troika agreement. Then, we focused on the budgetary cuts-related risks over the social performance of the care system. Evidence suggests that structural reforms in the health care sector in the troika period had positive effects in terms of drugs administration and consumption, on the one hand, and secondary care expenditures reduction, on the other hand. Nonetheless, we observed some divestitures on infrastructures and the worsening of access to health care services.

Do Austrian "INTEGRI (integrated care) projects" comply with international definitions and concepts?

One of the biggest challenges for European healthcare systems is the fragmentation of care. To overcome this challenge, integrated care (IC) approaches have been recently implemented. To further improve this method, current and past projects must be monitored and evaluated. However, since the definition of IC is very indistinct and varies significantly in literature, key elements have to be defined. The study design selected was a mixed-methods study that includes two approaches: a systematic literature review and qualitative content analysis of the data provided by the Ludwig Boltzmann Institute. Nine key elements of IC projects were identified in the literature review and subsequently compared with the main features coded from previous INTEGRI applications. The results showed that 41 of the applications presented seven or more criteria in their official submission form. The conclusion of the results can be drawn as a justification and validation of the INTEGRI criteria. Although the results are positive on the whole, three recommendations on possible improvements are given.

[Health services Research Faces New Challenges: Consequences for Definition and Concept]. / Versorgungsforschung vor neuen Herausforderungen: Konsequenzen für Definition und Konzept.

In Germany, Health Services Research (HSR) is undergoing rapid and impressive development. Starting from the translation of methods in individual health care (efficacy-effectiveness gap) and the social-scientific description as well as analysis of health care structures and processes, now it is the implementation of complex interventions on the organizational and system level that is the center of interest. This development is mainly triggered by the establishment of the so-called innovation funds by means of legislation in 2015, which has the task to evaluate structural changes and reforms in outpatient and integrated health care. Moreover, benefit and improvement at patient and population level is getting attention. Against this background, in this paper the current definition of HSR is modified so that the term "intervention" is extended to include organizational and system interventions, the focus on population is added to the patient perspective, and the orientation to appropriateness of care and improvement is integrated. Parallel to this, the theoretical throughput model as established by Pfaff in 2003 is updated, including 4 aspects: (1) the input factors of first order (resources of stakeholders) are expanded by complex interventions and active context as input factors of second order, (2) both undergoing modulation during the following throughput, (3) the final outcome is expanded by the population perspective, and (4) feedback loops from output and outcome to input and throughput are established. The "double complexity" of intervention and context as well as their interaction during throughput is the central and most important issue, because the interventions are highly context-sensitive and the complex context is most potent and poorly anticipated at the same time. Improvement science and implementation research represent fields of research from the perspective of improvement and the translation of knowledge and change of attitude, respectively, which are of great importance for HSR. Insofar as HSR is dealing with improvement and translation of complex interventions, the health care politics constitute an important transfer factor itself. Considering that, in the present situation, the political level represents both the main sponsor and the main demander of HSR results, improving methodological standards and further expansion of research structures of HSR are urgently needed.

Do federal and state audits increase compliance with a grant program to improve municipal infrastructure (AUDIT study): study protocol for a randomized controlled trial.

BACKGROUND: Poor governance and accountability compromise young democracies' efforts to provide public services critical for human development, including water, sanitation, health, and education. Evidence shows that accountability agencies like superior audit institutions can reduce corruption and waste in federal grant programs financing service infrastructure. However, little is know about their effect on compliance with grant reporting and resource allocation requirements, or about the causal mechanisms. This study protocol for an exploratory randomized controlled trial tests the hypothesis that federal and state audits increase compliance with a federal grant program to improve municipal service infrastructure serving marginalized households. METHODS/DESIGN: The AUDIT study is a block randomized, controlled, three-arm parallel group exploratory trial. A convenience sample of 5 municipalities in each of 17 states in Mexico (n=85) were block randomized to be audited by federal auditors (n=17), by state auditors (n=17), and a control condition outside the annual program of audits (n=51) in a 1:1:3 ratio. Replicable and verifiable randomization was performed using publicly available lottery numbers. Audited municipalities were included in the national program of audits and received standard audits on their use of federal public service infrastructure grants. Municipalities receiving moderate levels of grant transfers were recruited, as these were outside the auditing sampling frame--and hence audit program--or had negligible probabilities of ever being audited. The primary outcome measures capture compliance with the grant program and markers for the causal mechanisms, including deterrence and information effects. Secondary outcome measure include differences in audit reports across federal and state auditors, and measures like career concerns, political promotions, and political clientelism capturing synergistic effects with municipal accountability systems. The survey firm and research assistants assessing outcomes were blind to treatment status. DISCUSSION: This study will improve our understanding of local accountability systems for public service delivery in the 17 states under study, and may have downstream policy implications. The study design also demonstrates the use of verifiable and replicable randomization, and of sequentially partitioned hypotheses to reduce the Type I error rate in multiple hypothesis tests. TRIAL REGISTRATION: Controlled-trials.com Identifier ISRCTN22381841: Date registered 02/11/2012.

Public community orthodontics in Italy. Description of an experience.

AIM: To assess the reliability and simplicity of a method chosen for selecting subjects to be treated in the orthodontic system and for the acceptance of the method by the community. MATERIALS AND METHODS: 490 orthodontic patients received full dental examination. For each patient a table was prepared for the detection of malocclusion in which the occlusal characteristics according to the Norwegian Orthodontic Treatment Index (NOTI), the molar class and the teeth present were recorded. The parents of the examined children completed a questionnaire aimed at identifying their social ranking. In the same questionnaire, how many siblings the patient had was also asked. Each of the three parameters were rated alphanumerically and a score of 1 was given to each child; the sum of three scores gave the final result for the subject. Acceptance of the procedure in the general community was evaluated by the number of complaints received by the Public Relations Office (URP). RESULTS: The social classes most represented in the sample are "blue collar class" (42.2%) and "white collar class" (35.6%). There was an average of 2.1 children per family (SD=0.6). The distribution of the type and grading of the treatment need was similar throughout the different social classes. CONCLUSION: The chosen method proved reliable for two reasons: no complaints with the local URP and ease of application of the selected criteria.

Financing long-term care for frail elderly in France: the ghost reform.

Like many welfare states, France is faced with increasing demand for long term care (LTC) services. Public LTC coverage has evolved over the past 15 years, reaching a coverage depth of 70%. Nonetheless, it does not provide adequate and equitable financial protection for the growing number of frail elderly individuals, who are expected to constitute 3% of the population by the year 2060. Since 2005, various financing reform proposals have been debated, ranging from a newly covered risk under the social security system to targeted subsidies for private LTC insurance. However, to date no reform measure has been enacted. This article provides a brief history of publicly financed LTC in France in order to provide a context for the ongoing debate, including the positions and relative political power of the various stakeholders and the doubtful short-term prospect for reform.

[Complementary medicine and scientific pluralism--from governmental research funding to the dialogue forum of pluralism in medicine]. / Komplementärmedizin und Wissenschaftspluralismus--von der staatlichen Forschungsförderung zum Dialogforum Pluralismus in der Medizin.

Medicine is based on a pluralism of different ways of thinking and practical approaches. Given this assumption, the history and experiences of the 2 German governmental research funding programs 'Unconventional Methods of Cancer' (UMK) and 'Unconventional Medicine Directions' (UMR) are described from the perspective of the project supporter of 2 working groups that were based at the University of Witten/Herdecke, Germany, on behalf of the federal government. The results of a nationwide inventory analysis conducted under my direction in the years 1989­1992 showed a distinct lack of human and infrastructural resources for competitive research for complementary medicine at that time. The field of complementary medicine was found to be very heterogeneous and was divided into procedures without any visible research interest, but also contained approaches nourishing mainstream medicine by its different paradigm. The representatives of complementary medicine were and still are recognizably interested in evaluative, empirical research. The following contains our funding recommendations made for the relevant ministries, the advertised funding issues, and the research activities carried out. Although this governmental research funding was limited, a signal function can be awarded, retrospectively. For the subsequent period, there has been a significant improvement in infrastructural, staff, and research conditions. This development led to a significant increase in the level of quality and the acceptability of research results. As a result of an increased willingness for cooperations, the foundations, concerns, and activities of the 'dialogue forum pluralism in medicine' set up in 2000 are presented and compared with the situation at the time of research funding by government. 'Integrative Medicine' is currently being favored and welcomed as a sign of better mutual acceptance. Nevertheless, complementary medicine is still seen as being creative, enriching medical and health care, improving the patient-centeredness, and thus as an educational (unrest) element (of agitation).

[Implementing models of cross-sectoral mental health care (integrated health care, regional psychiatry budget) in Germany: systematic literature review]. / Systematische Literaturübersicht zur Implementierung der sektorübergreifenden Versorgung (Regionalbudget, integrierte Versorgung) in Deutschland.

OBJECTIVE: Cross-sectoral integrated health-care and the regional psychiatry budget are two models of cross-sectoral health care (comprising in-patient and out-patient care) in Germany. Both models of financing were created in order to overcome the so-called fragmentation in German health care. The regional psychiatry budget is a specific solution for psychiatric services whereas integrated health care models can be developed for all areas of health care. The purpose of this overview is to elucidate both the current state of implementation of these models and the results of evaluation research. METHODS: Systematic literature review, additional manual search. RESULTS: 28 journal articles and 38 websites referring to 21 projects were identified. The projects are highly heterogenuous in terms of size, included populations and services, aims, and steering-function (concerning the different pathways of care). CONCLUSIONS: The projects yield innovative models of mental health care capable of competing with the co-existing traditional financing systems of in-patient and out-patient services. The future of mental health care organisation in Germany is currently open and under political discussion.

Outcome evaluation of a state comprehensive cancer control plan: laying the foundation.

CONTEXT: Rigorous outcome evaluation is essential to monitor progress toward achieving goals and objectives in comprehensive cancer control plans (CCCPs). OBJECTIVE: This report describes a systematic approach for an initial outcome evaluation of a CCCP. DESIGN: Using the Centers for Disease Control and Prevention evaluation framework, the evaluation focused on (1) organizing cancer plan objectives by anatomic site and risk factors, (2) rating each according to clarity and data availability, (3) the subsequent evaluation of clearly stated objectives with available outcome data, and (4) mapping allocation of implementation grants for local cancer control back to the CCCP objectives. SETTING: South Carolina. MAIN OUTCOME MEASURES: Evaluation outcomes included (1) a detailed account of CCCP objectives by topic area, (2) a systematic rating of level of clarity and availability of data to measure CCCP objectives, (3) a systematic assessment of attainment of measurable objectives, and (4) a summary of how cancer control grant funds were allocated and mapped to CCCP objectives. RESULTS: A system was developed to evaluate the extent to which cancer plan objectives were measurable as written with data available for monitoring. Twenty-one of 64 objectives (33%) in the South Carolina's CCCP were measurable as written with data available. Of the 21 clear and measurable objectives, 38% were not met, 38% were partially met, and 24% were met. Grant allocations were summarized across CCCP chapters, revealing that prevention and early detection were the most heavily funded CCCP areas. CONCLUSIONS: This evaluation highlights a practical, rigorous approach for generating evidence required to monitor progress, enhance planning efforts, and recommend improvements to a CCCP.

Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia.

BACKGROUND: In many developing countries, the maternal mortality ratio remains high with huge poor-rich inequalities. Programmes aimed at improving maternal health and preventing maternal mortality often fail to reach poor women. Vouchers in health and Health Equity Funds (HEFs) constitute a financial mechanism to improve access to priority health services for the poor. We assess their effectiveness in improving access to skilled birth attendants for poor women in three rural health districts in Cambodia and draw lessons for further improvement and scaling-up. METHODS: Data on utilisation of voucher and HEF schemes and on deliveries in public health facilities between 2006 and 2008 were extracted from the available database, reports and the routine health information system. Qualitative data were collected through focus group discussions and key informant interviews. We examined the trend of facility deliveries between 2006 and 2008 in the three health districts and compared this with the situation in other rural districts without voucher and HEF schemes. An operational analysis of the voucher scheme was carried out to assess its effectiveness at different stages of operation. RESULTS: Facility deliveries increased sharply from 16.3% of the expected number of births in 2006 to 44.9% in 2008 after the introduction of voucher and HEF schemes, not only for voucher and HEF beneficiaries, but also for self-paid deliveries. The increase was much more substantial than in comparable districts lacking voucher and HEF schemes. In 2008, voucher and HEF beneficiaries accounted for 40.6% of the expected number of births among the poor. We also outline several limitations of the voucher scheme. CONCLUSIONS: Vouchers plus HEFs, if carefully designed and implemented, have a strong potential for reducing financial barriers and hence improving access to skilled birth attendants for poor women. To achieve their full potential, vouchers and HEFs require other interventions to ensure the supply of sufficient quality maternity services and to address other non-financial barriers to demand. If these conditions are met, voucher and HEF schemes can be further scaled up under close monitoring and evaluation.

Is health care financing in Uganda equitable?

INTRODUCTION: Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. Equitable financing is based on: financial protection, progressive financing and cross-subsidies. This paper describes Uganda's health care financing landscape and documents the key equity issues associated with the current financing mechanisms. METHODS: We extensively reviewed government documents and relevant literature and conducted key informant interviews, with the aim of assessing whether Uganda's health care financing mechanisms exhibited the key principles of fair financing. RESULTS: Uganda's health sector remains significantly under-funded, mainly relying on private sources of financing, especially out-of-pocket spending. At 9.6 % of total government expenditure, public spending on health is far below the Abuja target of 15% that GoU committed to. Prepayments form a small proportion of funding for Uganda's health sector. There is limited cross-subsidisation and high fragmentation within and between health financing mechanisms, mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms. Without compulsory health insurance and low coverage of private health insurance, Uganda has limited pooling of resources, and hence minimal cross-subsidisation. Although tax revenue is equitable, the remaining financing mechanisms for Uganda are inequitable due to their regressive nature, their lack of financial protection and limited cross-subsidisation. CONCLUSION: Overall, Uganda's current health financing is inequitable and fragmented. The government should take explicit action to promote equitable health care financing by establishing pre-payment schemes, enhancing cross-subsidisation mechanisms and through appropriate integration of financing mechanisms.

Reforming funding for chronic illness: Medicare-CDM.

Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary "tools" for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding. The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support.

Casemix in the Islamic Republic of Iran: current knowledge and attitudes of health care staff.

Casemix is a tool that classifies patients according to their clinical similarity and the homogeneity of resources required. A descriptive study was conducted to assess the level of knowledge and attitude toward the casemix-based funding system among staff working in the Iranian Social Security Organization in Tehran. The survey showed that knowledge of casemix and diagnosis-related groups (DRG) was poor among the study group and any attempt to implement the casemix system--which about three-quarters of high-level staff had never heard of--would be likely to fail. This highlights the necessity for creating awareness of the casemix and DRG systems among the hospital staff before any action takes place.