Inclusion of people with disabilities in Chilean health policy: a policy analysis.

BACKGROUND: Around 18% of the population in Chile has disabilities. Evidence shows that this population has greater healthcare needs, yet they face barriers to accessing healthcare due to health system failures. This paper aims to assess the inclusion of people with disabilities in health policy documents and to explore the perceptions of key national stakeholders regarding the policy context, policy processes, and actors involved. METHODS: A policy content analysis was conducted of 12 health policy documents using the EquiFrame framework, adapted to assess disability inclusion. Documents were reviewed and rated on their quality of commitment against 21 core concepts of human rights in the framework. Key national stakeholders (n = 15) were interviewed, and data were thematically analysed under the Walt and Gilson Policy Analysis Triangle, using NVivo R1. RESULTS: Core human rights concepts of disability were mentioned at least once in nearly all health policy documents (92%). However, 50% had poor policy commitments for disability. Across policies, Prevention of health conditions was the main human rights concept reflected, while Privacy of information was the least referenced concept. Participants described a fragmented disability movement and health policy, related to a dominant biomedical model of disability. It appeared that disability was not prioritized in the health policy agenda, due to ineffective mainstreaming of disability by the Government and the limited influence and engagement of civil society in policy processes. Moreover, the limited existing policy framework on disability inclusion is not being implemented effectively. This implementation gap was attributed to lack of financing, leadership, and human resources, coupled with low monitoring of disability inclusion. CONCLUSIONS: Improvements are needed in both the development and implementation of disability-inclusive health policies in Chile, to support the achievement of the right to healthcare for people with disabilities and ensuring that the health system truly "leaves no one behind".

INTRODUCCIóN: Alrededor del 18% de la población de Chile tiene discapacidad. Los datos demuestran que esta población tiene mayores necesidades de salud, pero se enfrenta a barreras para acceder a la salud debido a las deficiencias del sistema sanitario. El objetivo de este estudio es evaluar la inclusión de las personas con discapacidad en las políticas sanitarias y explorar las percepciones de actores nacionales en relación al contexto político, los procesos políticos y los actores implicados. MéTODOS: Se realizó un análisis de contenido de 12 políticas sanitarias utilizando el marco EquiFrame, adaptado para discapacidad. Se calificó la calidad de compromiso de las políticas con respecto a 21 conceptos de derechos humanos del EquiFrame. Se entrevistó a 15 actores nacionales, y los datos se analizaron temáticamente según el Triángulo de Políticas de Walt y Gilson, utilizando NVivo R1. RESULTADOS: Los conceptos de derechos humanos en materia de discapacidad se mencionaron al menos una vez en casi todas las políticas sanitarias (92%). Sin embargo, en el 50% de los casos los compromisos políticos en materia de discapacidad eran escasos. En todas las políticas, la Prevención de los problemas de salud fue el principal concepto de derechos humanos reflejado, mientras que la Privacidad de la información fue el concepto menos mencionado. Los participantes describieron un movimiento de la discapacidad y una política sanitaria fragmentados, relacionados con un modelo biomédico dominante de la discapacidad. Pareciera que la discapacidad no es prioritaria en la agenda política sanitaria, debido a su ineficaz integración por parte del Gobierno y a la limitada participación de la sociedad civil en los procesos políticos. Además, el limitado marco político existente sobre salud inclusiva no se está implementando eficazmente. Esta deficiencia en la implementación se atribuyó a la falta de financiamiento, liderazgo y recursos humanos, junto con el escaso monitoreo de la discapacidad. CONCLUSIONES: Se requieren mejoras tanto en el desarrollo como en la implementación de políticas de salud inclusivas de la discapacidad en Chile, para apoyar el alcance del derecho a la salud de las personas con discapacidad y asegurar que el sistema de salud realmente "no deje a nadie atrás".

An analysis of migration and implications for health in government policy of South Africa.

For over a decade, the global health community has advanced policy engagement with migration and health, as reflected in multiple global-led initiatives. These initiatives have called on governments to provide universal health coverage to all people, regardless of their migratory and/or legal status. South Africa is a middle-income country that experiences high levels of cross-border and internal migration, with the right to health enshrined in its Constitution. A National Health Insurance Bill also commits the South African public health system to universal health coverage, including for migrant and mobile groups. We conducted a study of government policy documents (from the health sector and other sectors) that in our view should be relevant to issues of migration and health, at national and subnational levels in South Africa. We did so to explore how migration is framed by key government decision makers, and to understand whether positions present in the documents support a migrant-aware and migrant-inclusive approach, in line with South Africa's policy commitments. This study was conducted between 2019 and 2021, and included analysis of 227 documents, from 2002-2019. Fewer than half the documents identified (101) engaged directly with migration as an issue, indicating a lack of prioritisation in the policy discourse. Across these documents, we found that the language or discourse across government levels and sectors focused mainly on the potential negative aspects of migration, including in policies that explicitly refer to health. The discourse often emphasised the prevalence of cross-border migration and diseases, the relationship between immigration and security risks, and the burden of migration on health systems and other government resources. These positions attribute blame to migrant groups, potentially fuelling nationalist and anti-migrant sentiment and largely obscuring the issue of internal mobility, all of which could also undermine the constructive engagement necessary to support effective responses to migration and health. We provide suggestions on how to advance engagement with issues of migration and health in order for South Africa and countries of a similar context in regard to migration to meet the goal of inclusion and equity for migrant and mobile groups.

Female political representation and the gender health gap: a cross-national analysis of 49 European countries.

BACKGROUND: Does increased female participation in the social and political life of a country improve health? Social participation may improve health because it ensures that the concerns of all people are heard by key decision-makers. More specifically, when women's social participation increases this may lead to health gains because women are more likely to vote for leaders and lobby for policies that will enhance the health of everyone. This article tries to examine whether female participation is correlated with measures of health inequality. METHODS: We draw on data from the World Health Organization Health Equity Status Report initiative and the Varieties of Democracy project to assess whether health is better and health inequalities are smaller in countries where female political representation is greater. RESULTS: We find consistent evidence that greater female political representation is associated with lower geographical inequalities in infant mortality, smaller inequalities in self-reported health (for both women and men) and fewer disability-adjusted life-years lost for women and men. Finally, we find that greater female political representation is not only correlated with better health for men and women but is also correlated with a smaller gap between men and women because men seem to experience better health in such contexts. CONCLUSIONS: Greater female political representation is associated with better health for everyone and smaller inequalities.

Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

The impact of non-pharmaceutical interventions on COVID-19 epidemic growth in the 37 OECD member states.

We estimated the impact of a comprehensive set of non-pharmeceutical interventions on the COVID-19 epidemic growth rate across the 37 member states of the Organisation for Economic Co-operation and Development during the early phase of the COVID-19 pandemic and between October and December 2020. For this task, we conducted a data-driven, longitudinal analysis using a multilevel modelling approach with both maximum likelihood and Bayesian estimation. We found that during the early phase of the epidemic: implementing restrictions on gatherings of more than 100 people, between 11 and 100 people, and 10 people or less was associated with a respective average reduction of 2.58%, 2.78% and 2.81% in the daily growth rate in weekly confirmed cases; requiring closing for some sectors or for all but essential workplaces with an average reduction of 1.51% and 1.78%; requiring closing of some school levels or all school levels with an average reduction of 1.12% or 1.65%; recommending mask wearing with an average reduction of 0.45%, requiring mask wearing country-wide in specific public spaces or in specific geographical areas within the country with an average reduction of 0.44%, requiring mask-wearing country-wide in all public places or all public places where social distancing is not possible with an average reduction of 0.96%; and number of tests per thousand population with an average reduction of 0.02% per unit increase. Between October and December 2020 work closing requirements and testing policy were significant predictors of the epidemic growth rate. These findings provide evidence to support policy decision-making regarding which NPIs to implement to control the spread of the COVID-19 pandemic.

Research on the move: exploring WhatsApp as a tool for understanding the intersections between migration, mobility, health and gender in South Africa.

BACKGROUND: Reflecting global norms, South Africa is associated with high levels of cross-border and internal population mobility, yet migration-aware health system responses are lacking. Existing literature highlights three methodological challenges limiting the development of evidence-informed responses to migration and health: (1) lack of engagement with the process of migration; (2) exclusion of internal migrants; and (3) lack of methodologies that are able to capture 'real-time' data about health needs and healthcare seeking experiences over both time and place. In this paper, we reflect on a four-month pilot project which explored the use of WhatsApp Messenger - a popular mobile phone application used widely in sub-Saharan Africa - and assessed its feasibility as a research tool with migrant and mobile populations in order to inform a larger study that would address these challenges. METHOD: A four-month pilot was undertaken with eleven participants between October 2019 and January 2020. Using Survey Node, an online platform that allows for the automatic administration of surveys through WhatsApp, monthly surveys were administered. The GPS coordinates of participants were also obtained. Recruited through civil society partners in Gauteng, participants were over the age of 18, comfortable engaging in English, and owned WhatsApp compatible cell phones. Enrolment involved an administered survey and training participants in the study protocol. Participants received reimbursement for their travel costs and monthly cell phone data. RESULTS: Out of a possible eighty eight survey and location responses, sixty one were received. In general, participants responded consistently to the monthly surveys and shared their location when prompted. Survey Node proved an efficient and effective way to administer surveys through WhatsApp. Location sharing via WhatsApp proved cumbersome and led to the development of a secure platform through which participants could share their location. Ethical concerns about data sharing over WhatsApp were addressed. CONCLUSIONS: The success of the pilot indicates that WhatsApp can be used as a tool for data collection with migrant and mobile populations, and has informed the finalisation of the main study. Key lessons learnt included the importance of research design and processes for participant enrolment, and ensuring that the ethical concerns associated with WhatsApp are addressed.

De-escalation strategies for non-pharmaceutical interventions following infectious disease outbreaks: a rapid review and a proposed dynamic de-escalation framework.

BACKGROUND: The severity of COVID-19, as well as the speed and scale of its spread, has posed a global challenge. Countries around the world have implemented stringent non-pharmaceutical interventions (NPI) to control transmission and prevent health systems from being overwhelmed. These NPI have had profound negative social and economic impacts. With the timeline to worldwide vaccine roll-out being uncertain, governments need to consider to what extent they need to implement and how to de-escalate these NPI. This rapid review collates de-escalation criteria reported in the literature to provide a guide to criteria that could be used as part of de-escalation strategies globally. METHODS: We reviewed literature published since 2000 relating to pandemics and infectious disease outbreaks. The searches included Embase.com (includes Embase and Medline), LitCovid, grey literature searching, reference harvesting and citation tracking. Over 1,700 documents were reviewed, with 39 documents reporting de-escalation criteria included in the final analysis. Concepts retrieved through a thematic analysis of the included documents were interlinked to build a conceptual dynamic de-escalation framework. RESULTS: We identified 52 de-escalation criteria, the most common of which were clustered under surveillance (cited by 43 documents, 10 criteria e.g. ability to actively monitor confirmed cases and contact tracing), health system capacity (cited by 30 documents, 11 criteria, e.g. ability to treat all patients within normal capacity) and epidemiology (cited by 28 documents, 7 criteria, e.g. number or changes in case numbers). De-escalation is a gradual and bi-directional process, and resurgence of infections or emergence of variants of concerns can lead to partial or full re-escalation(s) of response and control measures in place. Hence, it is crucial to rely on a robust public health surveillance system. CONCLUSIONS: This rapid review focusing on de-escalation within the context of COVID-19 provides a conceptual framework and a guide to criteria that countries can use to formulate de-escalation plans.

Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?

BACKGROUND: Healthcare providers' (HCPs) professionalism refers to their commitment and ability to respond to the health needs of the communities they serve and to act in the best interest of patients. Despite attention to increasing the number of HCPs in low- and middle-income countries (LMIC), the quality of professional education delivered to HCPs and their resulting professionalism has been neglected. The Global Action Plan on Antimicrobial Resistance (AMR) seeks to reduce inappropriate use of antibiotics by urging patients to access antibiotics only through qualified HCPs, on the premise that qualified HCPs will act as more responsible and competent gatekeepers of access to antibiotics than unqualified HCPs. METHODS: We investigate whether weaknesses in HCP professionalism result in boundaries between qualified HCPs and unqualified providers being blurred, and how these weaknesses impact inappropriate provision of antibiotics by HCPs in two LMIC with increasing AMR-Pakistan and Cambodia. We conducted 85 in-depth interviews with HCPs, policymakers, and pharmaceutical industry representatives. Our thematic analysis was based on a conceptual framework of four components of professionalism and focused on identifying recurring findings in both countries. RESULTS: Despite many cultural and sociodemographic differences between Cambodia and Pakistan, there was a consistent finding that the behaviour of many qualified HCPs did not reflect their professional education. Our analysis identified five areas in which strengthening HCP education could enhance professionalism and reduce the inappropriate use of antibiotics: updating curricula to better cover the need for appropriate use of antibiotics; imparting stronger communication skills to manage patient demand for medications; inculcating essential professional ethics; building skills required for effective collaboration between doctors, pharmacists, and lay HCPs; and ensuring access to (unbiased) continuing medical education. CONCLUSIONS: In light of the weaknesses in HCP professionalism identified, we conclude that global guidelines urging patients to only seek care at qualified HCPs should consider whether HCP professional education is equipping them to act in the best interest of the patient and society. Our findings suggest that improvements to HCP professional education are needed urgently and that these should focus not only on the curriculum content and learning methods, but also on the social purpose of graduates.

Assessing COVID-19 through the lens of health systems' preparedness: time for a change.

The last months have left no-one in doubt that the COVID-19 pandemic is exerting enormous pressure on health systems around the world, bringing to light the sub-optimal resilience of even those classified as high-performing. This makes us re-think the extent to which we are using the appropriate metrics in evaluating health systems which, in the case of this pandemic, might have masked how unprepared some countries were. It also makes us reflect on the strength of our solidarity as a global community, as we observe that global health protection remains, as this pandemic shows, focused on protecting high income countries from public health threats originating in low and middle income countries. To change this course, and in times like this, all nations should come together under one umbrella to respond to the pandemic by sharing intellectual, human, and material resources. In order to work towards stronger and better prepared health systems, improved and resilience-relevant metrics are needed. Further, a new model of development assistance for health, one that is focused on stronger and more resilient health systems, should be the world's top priority.

Integrating tuberculosis and antimicrobial resistance control programmes.

Many low- and middle-income countries facing high levels of antimicrobial resistance, and the associated morbidity from ineffective treatment, also have a high burden of tuberculosis. Over recent decades many countries have developed effective laboratory and information systems for tuberculosis control. In this paper we describe how existing tuberculosis laboratory systems can be expanded to accommodate antimicrobial resistance functions. We show how such expansion in services may benefit tuberculosis case-finding and laboratory capacity through integration of laboratory services. We further summarize the synergies between high-level strategies on tuberculosis and antimicrobial resistance control. These provide a potential platform for the integration of programmes and illustrate how integration at the health-service delivery level for diagnostic services could occur in practice in a low- and middle-income setting. Many potential mutual benefits of integration exist, in terms of accelerated scale-up of diagnostic testing towards rational use of antimicrobial drugs as well as optimal use of resources and sharing of experience. Integration of vertical disease programmes with separate funding streams is not without challenges, however, and we also discuss barriers to integration and identify opportunities and incentives to overcome these.

De nombreux pays à revenu faible et intermédiaire qui sont confrontés à une forte résistance aux antimicrobiens ainsi qu'à la morbidité associée, due à l'inefficacité des traitements, sont aussi fortement touchés par la tuberculose. Ces dernières décennies, de nombreux pays ont mis au point des systèmes efficaces d'information et de laboratoire afin de combattre la tuberculose. Dans cet article, nous décrivons la manière dont les systèmes existants des laboratoires spécialisés dans la tuberculose peuvent être élargis afin d'intégrer des fonctions applicables à la résistance aux antimicrobiens. Nous montrons comment cet élargissement des services pourrait contribuer au dépistage de la tuberculose et aux capacités des laboratoires par l'intégration de services de laboratoire. Nous faisons par ailleurs le point sur les synergies entre les stratégies de haut niveau sur la tuberculose et la lutte contre la résistance aux antimicrobiens. Celles-ci offrent des possibilités pour l'intégration de programmes et illustrent la manière dont l'intégration au niveau de la prestation des services de diagnostic pourrait se faire en pratique dans les régions à revenu faible et intermédiaire. L'intégration pourrait apporter de nombreux bénéfices mutuels, comme l'expansion plus rapide des tests de diagnostic en vue d'une utilisation rationnelle des médicaments antimicrobiens, d'une utilisation optimale des ressources et d'un partage d'expérience. L'intégration de programmes verticaux de lutte contre les maladies, qui ont des sources de financement différentes, n'est cependant pas chose simple. Nous évoquons également les obstacles à cette intégration ainsi que les perspectives et les mesures incitatives pour les surmonter.

Muchos países de ingresos bajos y medianos que enfrentan altos niveles de resistencia a los antimicrobianos, así como la morbilidad asociada por un tratamiento ineficaz, también presentan una alta incidencia de tuberculosis. En las últimas décadas, muchos países han desarrollado sistemas efectivos de laboratorio e información para el control de la tuberculosis. En este documento describimos cómo los sistemas de laboratorio de tuberculosis existentes pueden ampliarse para dar cabida a las funciones de resistencia a los antimicrobianos. Mostramos cómo dicha expansión en los servicios puede beneficiar la búsqueda de casos de tuberculosis y la capacidad de laboratorio a través de la integración de los servicios de laboratorio. Resumimos las sinergias entre las estrategias de alto nivel sobre la tuberculosis y el control de la resistencia a los antimicrobianos. Estos proporcionan una plataforma potencial para la integración de programas e ilustran cómo la integración en el nivel de prestación de servicios de salud para los servicios de diagnóstico podría ocurrir en la práctica en un entorno de ingresos bajos y medianos. Existen muchos beneficios mutuos potenciales de la integración, en términos de una mejora acelerada de las pruebas de diagnóstico hacia el uso racional de los medicamentos antimicrobianos, así como el uso óptimo de los recursos y el intercambio de experiencias. Sin embargo, la integración de programas de enfermedades verticales con flujos de financiación separados no está exenta de desafíos, y también examinamos los obstáculos a la integración e identificamos oportunidades e incentivos para superarlas.

Evaluation of public subsidy for medical travel: does it protect against household impoverishment?

BACKGROUND: In resource-constrained health systems medical travel is a common alternative to seeking unavailable health services. This paper was motivated by the need to understand better the impact of such travel on households and health systems. METHODS: We used primary data from 344 subsidized and 471 non-subsidized inbound medical travellers during June to December 2013 drawn from the North, Centre and South regions of the Maldives where three international airports are located. Using a researcher-administered questionnaire to acquire data, we calculated annual out-of-pocket (OOP) spending on health, food and non-food items among households where at least one member had travelled to another country for medical care within the last year and estimated the poverty head count using household income as a living standard measure. RESULTS: Most of the socio demographic indicators, and costs of treatment abroad among Maldivian medical travellers were similar across different household income levels with no statistical difference between subsidized and non-subsidized travellers (p value: 0.499). The government subsidy across income quintiles was also similar indicating that the Maldivian health financing structure supports equality rather than being equity-sensitive. There was no statistical difference in OOP expenditure on medical care abroad and annual OOP expenditure on healthcare was similar across income quintiles. Diseases of the circulatory system, eye and musculoskeletal system had the most impoverishing effect - diseases for which half of the patients, or less, did not receive the public subsidy. Annually, 6 and 14% of the medical travellers in the Maldives fell into poverty ($2 per day) before and after making OOP payments to health care. CONCLUSION: Evidence of a strong association between predominant public financing of medical travel and equality was found. With universal eligibility to the government subsidy for medical travel, utilization of treatment abroad, medical expenditures abroad and OOP expenditures on health among Maldivian medical travellers were similar between the poor and the rich. However, we conclude mixed evidence on the linkages between public financing of medical travel and impoverishment which needs to be further explored with comparison of impoverishment levels between households with and without medical travel.

Understanding medical travel from a source country perspective: a cross sectional study of the experiences of medical travelers from the Maldives.

BACKGROUND: The resolution adopted in 2006 by the World Health Organization on international trade and health urges Member States to understand the implications of international trade and trade agreements for health and to address any challenges arising through policies and regulations. The government of Maldives is an importer of health services (with outgoing medical travelers), through offering a comprehensive universal health care package for its people that includes subsidized treatment abroad for services unavailable in the country. By the end of the first year of the scheme approximately US$11.6 m had been spent by the government of Maldives to treat patients abroad. In this study, affordability, continuity and quality of this care were assessed from the perspective of the medical traveler to provide recommendations for safer and more cost effective medical travel policy. RESULTS: Despite universal health care, a substantial proportion of Maldivian travelers have not accessed the government subsidy, and a third reported not having sufficient funds for the treatment episode abroad. Among the five most visited hospitals in this study, none were JCI accredited at the time of the study period and only three from India had undergone the National Accreditation Board for Hospitals (NABH) in India. Satisfaction with treatment received was high amongst travelers but concern for the continuity of care was very high, and more than a third of the patients had experienced complications arising from the treatment overseas. CONCLUSION: Source countries can use their bargaining power in the trade of health services to offer a more comprehensive package for medical travelers. Source countries with largely public funded health systems need to ensure that medical travel is truly affordable and universal, with measures for quality control such as the use of accredited foreign hospitals to make it safer and to impose measures that ensure the continuity of care for travelers.

Debate: can we achieve universal health coverage without a focus on disability?

BACKGROUND: The achievement of Universal Health Coverage (UHC) is a key aim of the global health agenda, and an important target of the Sustainable Development Goals. There is increasing recognition that some groups may fall behind in efforts to achieve UHC, including the 1 billion people globally living with disabilities. A fundamental question for debate is - can UHC be achieved without the inclusion of people with disabilities? MAIN TEXT: People with disabilities are more likely to experience poor health. They will therefore have greater need for general healthcare services, as well as rehabilitation and specialist services, related to their underlying impairment. People with disabilities also frequently face additional difficulties in accessing healthcare, incur greater costs when seeking healthcare and often report experiencing worse quality services than others. As a consequence of these different challenges, people with disabilities face specific and added difficulties across three dimensions of UHC: coverage, access to services needed, and at reasonable cost. A focus on people with disabilities is therefore essential to achieving UHC, particularly since they constitute 15% of the global population. To ensure the realisation of UHC is inclusive of and addresses the needs of people with disabilities, health systems need to adapt. A twin-tracked approach is recommended, which means that there is a focus on including people with disabilities in mainstream services, as well as targeting them with specific services needed. There also must be efforts to improve the quality of services (e.g. through healthcare staff training) and enhance cost protection for people with disabilities (e.g. through social protection). A key challenge to changing UHC strategies to be more inclusive is the lack of evidence on what is needed and works, and more research is needed urgently on this topic. CONCLUSIONS: It will be difficult to achieve UHC without a focus on people with disabilities. Changes made to improve coverage for people with disabilities will likely benefit a wider group, including older people, ethnic minorities, and people with short-term functional difficulties. Disability-inclusive strategies will therefore improve health system equity and ensure that we "Leave no one behind" as we move towards UHC.

Understanding and measuring quality of care: dealing with complexity.

Existing definitions and measurement approaches of quality of health care often fail to address the complexities involved in understanding quality of care. It is perceptions of quality, rather than clinical indicators of quality, that drive service utilization and are essential to increasing demand. Here we reflect on the nature of quality, how perceptions of quality influence health systems and what such perceptions indicate about measurement of quality within health systems. We discuss six specific challenges related to the conceptualization and measurement of the quality of care: perceived quality as a driver of service utilization; quality as a concept shaped over time through experience; responsiveness as a key attribute of quality; the role of management and other so-called upstream factors; quality as a social construct co-produced by families, individuals, networks and providers; and the implications of our observations for measurement. Within the communities and societies where care is provided, quality of care cannot be understood outside social norms, relationships, trust and values. We need to improve not only technical quality but also acceptability, responsiveness and levels of patient-provider trust. Measurement approaches need to be reconsidered. An improved understanding of all the attributes of quality in health systems and their interrelationships could support the expansion of access to essential health interventions.

Les définitions et approches d'évaluation existantes de la qualité des soins de santé ne couvrent souvent pas toutes les complexités en jeu pour correctement appréhender la qualité des soins. Ce sont les perceptions de la qualité, plutôt que les indicateurs cliniques de la qualité, qui expliquent généralement le recours aux services de soins et déterminent l'augmentation de la demande. Dans cet article, nous nous penchons sur la nature de la qualité, sur la manière dont les perceptions de la qualité influent sur les systèmes de santé et sur ce que ces perceptions indiquent en termes d'évaluation de la qualité au sein des systèmes de santé. Nous y évoquons six défis spécifiques, liés à la conceptualisation et à l'évaluation de la qualité des soins: la qualité perçue en tant que facteur déterminant de l'utilisation des services; la qualité en tant que concept façonné au fil du temps par l'expérience; la réactivité en tant que caractéristique clé de la qualité; le rôle des pratiques de gestion et d'autres facteurs « en amont ¼; la qualité en tant que construction sociale coproduite par les familles, les individus, les réseaux et les prestataires; et les implications de nos observations en termes d'évaluation. Dans les communautés et sociétés dans lesquelles les soins sont dispensés, la qualité des soins ne peut pas être comprise indépendamment des normes, relations et valeurs sociales et du climat de confiance en présence. Nous devons améliorer non seulement la qualité technique mais aussi l'acceptabilité, la réactivité et le climat de confiance entre les patients et les prestataires de soins. Il est donc nécessaire de reconsidérer les approches d'évaluation. Une meilleure compréhension de toutes les facettes de la qualité dans les systèmes de santé et de leurs corrélations pourrait contribuer à étendre l'accès aux interventions sanitaires essentielles.

Las definiciones y los enfoques de medición existentes de la calidad de la atención sanitaria no suelen abordar las complejidades involucradas en la comprensión de la calidad de la atención. Son las percepciones de la calidad, y no los indicadores clínicos de calidad, lo que impulsa la utilización de los servicios y son esenciales para el aumento de la demanda. Este artículo se centra en la naturaleza de la calidad, la forma en que las percepciones de la calidad influencian los sistemas sanitarios y qué indican dichas percepciones sobre la medición de la calidad de los sistemas sanitarios. Se analizan seis desafíos específicos relacionados con la conceptualizacion y la medición de la calidad de la atención: la calidad aparente como un impulsor de la utilización de los servicios; la calidad como un concepto formado con el tiempo a través de la experiencia; la capacidad de respuesta como un atributo fundamental de la calidad; el papel de la gestión y otros factores denominados previos; la calidad como una construcción social coproducida por las familias, individuos, redes y profesionales; y las implicaciones de nuestras observaciones para la medición. Dentro de las comunidades y sociedades en las que se ofrece atención, la calidad de la misma no puede concebirse sin tener en cuenta las normas sociales, las relaciones, la confianza y los valores. Es necesario mejorar la calidad técnica, así como la aceptación, la capacidad de respuesta y los niveles de confianza entre paciente y profesional. Conviene reconsiderar los enfoques de medición. Una mejor comprensión de todos los atributos de la calidad de los sistemas sanitarios y sus interrelaciones podría dar apoyo a la expansión del acceso a intervenciones sanitarias básicas.

Medical tourism in Thailand: a cross-sectional study.

OBJECTIVE: To investigate the magnitude and characteristics of medical tourism in Thailand and the impact of such tourism on the Thai health system and economy. METHODS: In 2010, we checked the records of all visits to five private hospitals that are estimated to cover 63% of all foreign patients. We reviewed hospital records of foreign patients and obtained data on their countries of origin, diagnoses and interventions. We surveyed 293 medical tourists to collect demographic characteristics and information on their expenditure and travelling companions. To help understand the impact of medical tourism on the Thai health system, we also interviewed 15 hospital executives and 28 service providers from the private hospitals. FINDINGS: We obtained 911,913 records of hospital visits, of which 324,906 came from 104,830 medical tourists. We estimated that there were 167,000 medical tourists in Thailand in 2010. Of the medical tourists who attended our study hospitals, 67,987 (64.8%) came from the eastern Mediterranean region or Asia and 109,509 (34%) of them were treated for simple and uncomplicated conditions - i.e. general check-ups and medical consultations. The mean self-reported non-medical expenditure was 2750 United States dollars. According to the hospital staff interviewed, medical tourism in 2010 brought benefits to - and apparently had no negative impacts on - the Thai health system and economy. CONCLUSION: We estimate that the total number of medical tourists visiting Thailand is about 10% of previous national government estimates of 1.2 million. Such tourists appear to bring economic benefits to Thailand and to have negligible effects on the health system.

Considerations for a Human Rights Impact Assessment of a Population Wide Treatment for HIV Prevention Intervention.

Increasing attention is being paid to the potential of anti-retroviral treatment (ART) for HIV prevention. The possibility of eliminating HIV from a population through a universal test and treat intervention, where all people within a population are tested for HIV and all positive people immediately initiated on ART, as part of a wider prevention intervention, was first proposed in 2009. Several clinical trials testing this idea are now in inception phase. An intervention which relies on universally testing the entire population for HIV will pose challenges to human rights, including obtaining genuine consent to testing and treatment. It also requires a context in which people can live free from fear of stigma, discrimination and violence, and can access services they require. These challenges are distinct from the field of medical ethics which has traditionally governed clinical trials and focuses primarily on patient researcher relationship. This paper sets out the potential impact of a population wide treatment as prevention intervention on human rights. It identifies five human right principles of particular relevance: participation, accountability, the right to health, non-discrimination and equality, and consent and confidentiality. The paper proposes that explicit attention to human rights can strengthen a treatment as prevention intervention, contribute to mediating likely health systems challenges and offer insights on how to reach all sections of the population.

UK medical tourists in Thailand: they are not who you think they are.

BACKGROUND: Travel for medical treatment is an aspect of globalization and health that is comparatively less understood. Little is known about volume, characteristic and motivation of medical tourists, limiting understanding of effects on health systems and patients. Thailand is amongst a handful of countries that have positioned themselves as medical tourism destination. This paper examines in unprecedented detail volume and characteristics of medical tourists who travel from the UK to Thailand for treatment. METHODS: As part of a wider medical tourism study, authors gained access to over 4000 patient records from the five largest private hospitals in Thailand. These included information on country of origin, gender, age, arrival month, hospitalization, diagnosis, procedures, length of stay, medical expenditure and type of payment. Patient records were analysed to understand who travels and findings were triangulated with data from the UK International Passenger Survey (IPS). RESULTS: 104,830 medical tourists visited these hospitals in Thailand in 2010. While patients originate all over the world, UK medical tourists represent the largest group amongst Europeans. The majority UK medical tourists (60%) have comparatively small, elective procedures, costing less than USD 500. A significant minority of patients travel for more serious orthopedic and cardiothoracic procedures. Data of individual patient records from Thailand shows a higher number of UK patients traveled to Thailand than indicated by the IPS. CONCLUSIONS: Thailand is attracting a large number of medical tourists including larger numbers of UK patients than previously estimated. However, as many patients travel for comparatively minor procedures treatment may not be their primary motivation for travel. The small but significant proportion of older UK residents traveling for complex procedures may point to challenges within the NHS.