Understanding the Role of Values in Health Policy Decision-Making From the Perspective of Policy-Makers and Stakeholders: A Multiple-Case Embedded Study in Chile and Colombia.

BACKGROUND: Chile and Colombia are examples of Latin American countries with health systems shaped by similar values. Recently, both countries have crafted policies to regulate the participation of private for-profit insurance companies in their health systems, but through very different mechanisms. This study asks: what values are important in the decision-making processes that crafted these policies? And how and why are they used? METHODS: An embedded multiple-case study design was carried out for 2 specific decisions in each country: (1) in Chile, the development of the Universal Plan of Explicit Entitlements -AUGE/GES - and mandating universal coverage of treatments for high-cost diseases; and (2) in Colombia, the declaration of health as a fundamental right and a mechanism to explicitly exclude technologies that cannot be publicly funded. We interviewed key informants involved in one or more of the decisions and/or in the policy analysis and development process that contributed to the eventual decision. The data analysis involved a constant comparative approach and thematic analysis for each case study. RESULTS: From the 40 individuals who were invited, 28 key informants participated. A tension between 2 important values was identified for each decision (eg, solidarity vs. individualism for the AUGE/GES plan in Chile; human dignity vs. sustainability for the declaration of the right to health in Colombia). Policy-makers used values in the decisionmaking process to frame problems in meaningful ways, to guide policy development, as a pragmatic instrument to make decisions, and as a way to legitimize decisions. In Chile, values such as individualism and free choice were incorporated in decision-making because attaining private health insurance was seen as an indicator of improved personal economic status. In Colombia, human dignity was incorporated as the core value because the Constitutional Court asserted its importance in its use of judicial activism as a check on the power of the executive and legislative branches. CONCLUSION: There is an opportunity to open further exploration of the role of values in different health decisions, political sectors besides health, and even other jurisdictions.

Is Canada Ready to Partner for Value-Based Healthcare?

Global experience demonstrates that the transition of healthcare systems towards better value requires the collaboration of multiple actors, including health industry. Globally, several initiatives are already demonstrating the power of value-based partnerships between public and private sectors.

[General characteristics of medical education in Mexico. A look from medical schools]. / Características generales de la educación médica en México. Una mirada desde las escuelas de medicina.

OBJECTIVE: To know the characteristics of medical education and identify its strengths and weaknesses. MATERIALS AND METHODS: A transversal and quantitative study of the characteristics of medical education in 29 medical schools in Mexico was carried out, between April and September 2017. Questionnaire with Likert scale was applied to explore context, regulation, structure, process, results and impact of medical education. Bivariate analysis was performed with a Chi square test and the significance level was equal to or less than 0.05. RESULTS: The political context obtained 64%, economical context 10% and mechanisms of regulation 31%. The educational structure was 61% and the social impact was 93%. CONCLUSIONS: Public policies, regulatory mechanisms and public investment must be strengthened to improve the quality of medical education.

OBJETIVO: Conocer las características de la educación médica e identificar sus fortalezas y debilidades. MATERIAL Y MÉTODOS: Se realizó un estudio transversal y cuantitativo para conocer las características de la educación médica en 29 escuelas de medicina en México, entre abril y septiembre de 2017. Se utilizó un cuestionario con escala tipo Likert para explorar el contexto, la regulación, la estructura, el proceso, los resultados y el impacto de la educación médica. Se realizó un análisis bivariado con ji cuadrada y una significancia estadística de p igual o menor a 0.05. RESULTADOS: El contexto político obtuvo 64%, el contexto económico 10%, los mecanismos de regulación 31%, la estructura educativa 61% y el impacto social 93%. CONCLUSIONES: Se requiere fortalecer las políticas públicas, la regulación y la inversión pública, para mejorar la calidad de la educación médica.

CKD prevention: Perspectives in Hong Kong.

Hong Kong experiences a progressive rise in the prevalence of treated end-stage renal disease (ESRD) as recorded by the Hong Kong Renal Registry managed by the Hospital Authority (HA) that takes care of 90 - 95% of the ESRD burden. The CKD burden is envisaged to be high, as reflected by 2 initiatives - SHARE which detected a high prevalence of urine or blood pressure abnormalities among 1,201 asymptomatic individuals who underwent screening, and RISKS that aimed to further characterize the spread of CKD in the asymptomatic population. For CKD prevention, two statutory bodies - the HA and Hong Kong College of Physicians (HKCP), and two non-governmental organizations - Hong Kong Society of Nephrology (HKSN) and Hong Kong Kidney Foundation (HKKF), all have a role to play. The Central Renal Committee (CRC) operated under HA co-produces with HKCP and HKSN a clinical practice guideline for the provision of renal service in Hong Kong which includes CKD care and prevention. HKSN now holds annual educational symposia and a Continuous Medical Education (CME) course in partnership with the HKCP and Asian Pacific Society of Nephrology in addition to its Annual Scientific Meeting. The HKSN also provides a collective International Society of Nephrology (ISN) membership for all its full members to enhance education and other pertinent initiatives. For public education, the HKSN and HKKF participate in the annual World Kidney Day event and organize free blood pressure and CKD surveys in public housing estates to increase public awareness of CKD. The latter is also effected via regular promotion through the mass media.

Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage.

BACKGROUND: A case study was prepared examining government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. METHODS: Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study's findings were validated during two meetings with a broad set of stakeholders. RESULTS: Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship's evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the "good will" of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. CONCLUSIONS: GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. Governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.

Oncology services supply in Colombia.

OBJECTIVE: To characterize the current status of oncological services supply in Colombia. METHODS: A descriptive analysis of oncological services for cancer care in the adult and infant population that meet the requirements for operation according to the Special Register of Health Service Providers was carried out. The case - by - provider ratio was calculated based on the cancer incidence estimated for Colombia by the National Cancer Institute. RESULTS: Were identified 1,780 qualified oncology health services in the country related to specialties for providing care to cancer patients. Twenty five providers nationwide had all three qualified services: chemotherapy, radiotherapy and surgery. Nearly 50% of the offer was concentrated in Bogotá, Antioquia and Valle del Cauca. Putumayo and the Amazonas group departments, with the exception of Vaupés, did not show any oncological services. Healthcare Providers were responsible for 87.8%, and independent professionals provided 12.2%. Outpatient services were 66.7% of oncology services, 17.4% was diagnostic support services and therapeutic complementation, and 15.9% was surgical services. 87.9% of the oncological service offer in Colombia takes place in the private sector. CONCLUSIONS: The ratio between the service groups is asymmetric, with few providers jointly offering the basic services for oncology treatment, which reflects how provision is fragmented. It is necessary to redefine the concept of oncology service under a comprehensive care approach and the importance of enabling functional units, comprehensive treatment centers and other forms of care.

OBJETIVO: Caracterizar la situación actual de la oferta de servicios oncológicos en Colombia. MÉTODOS: Se realizó un análisis descriptivo de los servicios oncológicos para la atención de cáncer en población adulta e infantil, que cumplieron con los requisitos para su funcionamiento de acuerdo al Registro Especial de Prestadores de Servicios de Salud. La razón de casos por prestador se calculó a partir de la incidencia de cáncer estimada para Colombia por el Instituto Nacional de Cancerología. RESULTADOS: Se identificaron 1,780 servicios de salud oncológicos habilitados en el país relacionados con especialidades para la atención de pacientes con cáncer. 25 prestadores a nivel nacional contaron con los tres servicios habilitados: quimioterapia, radioterapia y cirugía. Cerca del 50% de la oferta se concentró en Bogotá, Antioquia y Valle del Cauca. Los departamentos de Putumayo y del grupo Amazonas, con excepción de Vaupés, no registraron servicios oncológicos. El 87.8% fue ofertado por Instituciones Prestadoras de Salud y el 12.2% fue provisto por profesionales independientes. El 66.7% de los servicios oncológicos eran de consulta externa, el 17.4% eran servicios de apoyo diagnóstico y complementación terapéutica y el 15.9% servicios quirúrgicos. El 87.9% de la oferta de servicios oncológicos en Colombia está en el sector privado. CONCLUSIONES: La relación entre los grupos de servicios es asimétrica, con pocos prestadores que ofertan de forma conjunta los servicios bases del tratamiento oncológico, lo cual refleja la fragmentación en la prestación. Es necesario redefinir el concepto de servicio oncológico bajo el enfoque de atención integral y la importancia de habilitar unidades funcionales, centros integrales de tratamiento y otras formas de atención.

Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study.

OBJECTIVES: Chiropractic care may have value in improving patient outcomes and decreasing opioid use, but little is known about the impetus for or process of incorporating these services into conventional medical settings. The purpose of this qualitative study was to describe organizational structures, care processes, and perceived value of chiropractic integration within U.S. private sector medical facilities. DESIGN: Multisite, comparative organizational case study. SETTINGS: Nine U.S. private sector medical facilities with on-site chiropractic care, including five hospitals and four clinics. PARTICIPANTS: One hundred and thirty-five key facility stakeholders including doctors of chiropractic (DCs), non-DC clinicians, support staff, administrators, and patients. METHODS: Researchers conducted 2-day site visits to all settings. Qualitative data were collected from audio-recorded, semi-structured, role-specified, individual interviews; standardized organizational data tables; and archival document review. A three-member, interdisciplinary team conducted thematic content analysis of verbatim transcripts using an existing conceptual framework and emergent codes. RESULTS: These nine medical facilities had unique organizational structures and reasons for initiating chiropractic care in their settings. Across sites, DCs were sought to take an evidence-based approach to patient care, work collaboratively within a multidisciplinary team, engage in interprofessional case management, and adopt organizational mission and values. Chiropractic clinics were implemented within existing human resources, physical plant, information technology, and administrative support systems, and often expanded over time to address patient demand. DCs usually were co-located with medical providers and integrated into the collaborative management of patients with musculoskeletal and co-morbid conditions. Delivery of chiropractic services was perceived to have high value among patients, medical providers, and administration. Patient clinical outcomes, patient satisfaction, provider productivity, and cost offset were identified as markers of clinic success. CONCLUSION: A diverse group of U.S. private sector medical facilities have implemented chiropractic clinics, and a wide variety of facility stakeholders report high satisfaction with the care provided.

Health and health care in Israel: an introduction.

Starting well before Independence in 1948, and over the ensuing six decades, Israel has built a robust, relatively efficient public system of health care, resulting in good health statistics throughout the life course. Because of the initiative of people living under the British Mandate for Palestine (1922-48), the development of many of today's health services predated the state's establishment by several decades. An extensive array of high-quality services and technologies is available to all residents, largely free at point of service, via the promulgation of the 1994 National Health Insurance Law. In addition to a strong medical academic culture, well equipped (albeit crowded) hospitals, and a robust primary-care infrastructure, the country has also developed some model national projects such as a programme for community quality indicators, an annual update of the national basket of services, and a strong system of research and education. Challenges include increasing privatisation of what was once largely a public system, and the underfunding in various sectors resulting in, among other challenges, relatively few acute hospital beds. Despite substantial organisational and financial investment, disparities persist based on ethnic origin or religion, other socioeconomic factors, and, regardless of the country's small size, a geographic maldistribution of resources. The Ministry of Health continues to be involved in the ownership and administration of many general hospitals and the direct payment for some health services (eg, geriatric institutional care), activities that distract it from its main task of planning for and supervising the whole health structure. Although the health-care system itself is very well integrated in relation to the country's two main ethnic groups (Israeli Arabs and Israeli Jews), we think that health in its widest sense might help provide a bridge to peace and reconciliation between the country and its neighbours.

Insights Into Collaborative Networks Of Nonprofit, Private, And Public Organizations That Address Complex Health Issues.

Community networks that include nonprofit, public, and private organizations have formed around many health issues, such as chronic disease management and healthy living and eating. Despite the increases in the numbers of and funding for cross-sector networks, and the growing literature about them, there are limited data and methods that can be used to assess their effectiveness and analyze their designs. We addressed this gap in knowledge by analyzing the characteristics of 260 cross-sector community health networks that collectively consisted of 7,816 organizations during the period 2008-15. We found that nonprofit organizations were more prevalent than private firms or government agencies in these networks. Traditional types of partners in community health networks such as hospitals, community health centers, and public health agencies were the most trusted and valued by other members of their networks. However, nontraditional partners, such as employer or business groups and colleges or universities, reported contributing relatively high numbers of resources to their networks. Further evidence is needed to inform collaborative management processes and policies as a mechanism for building what the Robert Wood Johnson Foundation describes as a culture of health.

The power of integration: radiotherapy and global palliative care.

Radiotherapy (RT) is a powerful tool for the palliation of the symptoms of advanced cancer, although access to it is limited or absent in many low- and middle-income countries (LMICs). There are multiple factors contributing to this, including assumptions about the economic feasibility of RT in LMICs, the logical challenges of building capacity to deliver it in those regions, and the lack of political support to drive change of this kind. It is encouraging that the problem of RT access has begun to be included in the global discourse on cancer control and that palliative care and RT have been incorporated into national cancer control plans in some LMICs. Further, RT twinning programs involving high- and low-resource settings have been established to improve knowledge transfer and exchange. However, without large-scale action, the consequences of limited access to RT in LMICs will become dire. The number of new cancer cases around the world is expected to double by 2030, with twice as many deaths occurring in LMICs as in high-income countries (HICs). A sustained and coordinated effort involving research, education, and advocacy is required to engage global institutions, universities, health care providers, policymakers, and private industry in the urgent need to build RT capacity and delivery in LMICs.

Investing in nursing and midwifery enterprise to empower women and strengthen health services and systems: An emerging global body of work.

In September of 2014, the Institute of Medicine (IOM) convened a global Rockefeller Bellagio Center workshop focusing on the largely overlooked area of investment in nursing and midwifery enterprise as a means for both empowering women and strengthening health systems and services. The report of this meeting, Empowering Women and Strengthening Health Systems and Services Through Investing in Nursing and Midwifery Enterprise: Lessons from Lower-Income Countries: Workshop Summary, was released in February, 2015. This report represents a pivotal point in a growing body of work begun in 2012, providing insights and perspectives of global experts that have resulted in subsequent global discussions and are paving the way for the future. This three-part article summarizes the initial exploration leading to the IOM workshop and report, followed by highlights and insights from the report and related meetings, and authors concluding discussion of implications for the future and next steps.

Investing in nursing and midwifery enterprise: Empowering women and strengthening health systems--A landscaping study of innovations in low- and middle-income countries.

Women's empowerment and global health promotion are both central aims in the development agenda, with positive associations and feedback loops between empowerment and health outcomes. To date, most of the work exploring connections between health and empowerment has focused on women as health consumers. This article summarizes a much longer landscape review that examines ways in which various health programs can empower women as providers, specifically nurses and midwives. We conducted a scan of the Center for Health Market Innovations database to identify how innovative health programs can create empowerment opportunities for nurses and midwives. We reviewed 94 programs, exploring nurses' and midwives' roles and inputs that contribute to their empowerment. There were four salient models: provider training, information and communications technologies, cooperatives, and clinical franchises. By documenting these approaches and their hallmarks for empowering female health workers, we hope to stimulate greater uptake of health innovations coupled with gender-empowerment opportunities globally. The full report with expanded methodology and findings is available online.

Application of preventive medicine resources in the health insurance system / Aplicação de recursos em medicina preventiva no sistema de saúde complementar

ABSTRACT Objective To identify the financial resources and investments provided for preventive medicine programs by health insurance companies of all kinds. Methods Data were collected from 30 large health insurance companies, with over 100 thousand individuals recorded, and registered at the Agência Nacional de Saúde Suplementar. Results It was possible to identify the percentage of participants of the programs in relation to the total number of beneficiaries of the health insurance companies, the prevention and promotion actions held in preventive medicine programs, the inclusion criteria for the programs, as well as the evaluation of human resources and organizational structure of the preventive medicine programs. Conclusion Most of the respondents (46.7%) invested more than US$ 50,000.00 in preventive medicine program, while 26.7% invested more than US$ 500,000.00. The remaining, about 20%, invested less than US$ 50,000.00, and 3.3% did not report the value applied.

RESUMO Objetivo Identificar os recursos financeiros e os investimentos disponibilizados para os programas de medicina preventiva em operadoras de saúde suplementar de todos os tipos. Métodos Foram levantados dados referentes a 30 operadoras de saúde registradas na Agência Nacional de Saúde Suplementar, de grande porte, com registro acima de 100 mil vidas. Resultados Foi possível identificar o porcentual de participantes dos programas em relação ao número total de beneficiários da operadora, as ações de prevenção e promoção realizadas nos programas de medicina preventiva, os critérios de inclusão nos programas, bem como a avaliação dos recursos humanos e da estrutura organizacional dos programas de medicina preventiva pesquisadas. Conclusão A maior parte dos pesquisados (46,7%) investiu mais de US$ 50,000.00 no programa de medicina preventiva, enquanto 26,7% investiram mais de US$ 500,000.00. Os restantes, cerca de 20%, investiram menos de US$ 50,000.00 e 3,3% não informaram o valor aplicado.

Accountable Care Organizations in California: Market Forces at Work?

Accountable care organizations (ACOs), one of the most recent and promising health care delivery innovations, encourage care coordination among providers. While ACOs hold promise for decreasing costs by reducing unnecessary procedures, improving resource use as a result of economies of scale and scope, ACOs also raise concerns about provider market power. This study examines the market-level competition factors that are associated with ACO participation and the number of ACOs. Using data from California, we find that higher levels of preexisting managed care leads to higher ACO entry and enrollment growth, while hospital concentration leads to fewer ACOs and lower enrollment. We find interesting results for physician market power - markets with concentrated physician markets have a smaller share of individuals in commercial ACOs but a larger number of commercial ACO organizations. This finding implies smaller ACOs in these markets.