Health policy and systems research in access to medicines: a prioritized agenda for low- and middle-income countries.

OBJECTIVES: To identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda. METHODS: The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM. RESULTS: A list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders' meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines? CONCLUSIONS: Our HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.

Establishing health systems financing research priorities in developing countries using a participatory methodology.

Donor funding for health systems financing (HSF) research is inadequate and often poorly aligned with national priorities. This study aimed to generate consensus about a core set of research issues that urgently require attention in order to facilitate policy development. There were three key inputs into the priority setting process: key-informant interviews with health policy makers, researchers, community and civil society representatives across twenty-four low- and middle-income countries in four regions; an overview of relevant reviews to identify research completed to date; and inputs from 12 key informants (largely researchers) at a consultative workshop. Nineteen priority research questions emerged from key-informant interviews. The overview of reviews was instructive in showing which health financing topics have had comparatively little written about them, despite being identified as important by key informants. The questions ranked as most important at the consultative workshop were: It is hoped that this work on HSF research priorities will complement calls for increased health systems research and evaluation by providing specific suggestions as to where new and existing research resources can best be invested. The list of high priority HSF research questions is being communicated to research funders and researchers in order to seek to influence global patterns of HSF research funding and activity. A "bottom up" approach to setting global research priorities such as that employed here should ensure that priorities are more sensitive to user needs.

Clinical predictors of occult pneumothoraces in severely injured blunt polytrauma patients: A prospective observational study.

INTRODUCTION: The supine antero-posterior (AP) chest radiograph (CXR) is an insensitive test for detecting post-traumatic pneumothoraces (PTXs). Computed tomography (CT) often identifies occult pneumothoraces (OPTXs) that were not diagnosed on CXR. The purpose of this study was to prospectively determine the incidence, and validate previously identified clinical predictors, of OPTXs after blunt trauma. METHODS: All severe blunt injured patients (injury severity score (ISS)>or=12) presenting to a level 1 trauma centre over a 17-month period were prospectively evaluated. Thoracoabdominal CT scans and corresponding CXRs were reviewed at the time of admission. Patients with OPTXs were compared to those with overt PTXs regarding incidence and previously identified predictive risk factors (subcutaneous emphysema, rib fractures, female sex and pulmonary contusion). RESULTS: CT imaging was performed concurrent to CXR in 405 blunt trauma patients (ISS>or=12) during the study period. PTXs were identified in 107 (26%) of the 405 patients. Eighty-one (76%) of these were occult when CXRs were interpreted by the trauma team. Concurrent chest trauma predictive of OPTXs was limited to subcutaneous emphysema (p=0.003). Rib fractures, pulmonary contusions and female sex were not predictive. CONCLUSIONS: OPTXs were missed in up to 76% of all seriously injured patients when CXRs were interpreted by the trauma team. This is higher than previously reported in retrospective studies and is likely based on the difficult conditions in which the trauma team functions. Subcutaneous emphysema remains a strong clinical predictor for concurrent OPTXs.

From Mexico to Mali: progress in health policy and systems research.

In 2004, the ministerial summit in Mexico drew attention to the historic neglect of health policy and systems research (HPSR) and called for increased funding, investment in national institutional capacity for HPSR, and resources for selected priority research topics. On the basis of meeting discussions, published reports, and available data from research funders and organisations in low-income and middle-income countries, we discuss how HPSR has evolved since the summit in Mexico. Funding for HPSR, particularly in low-income countries, is mainly supported by international and bilateral organisations. Increased interest in health systems has translated into increased support for HPSR. However, small grants and lack of coordination between funders inhibit capacity development, and substantial gaps remain between institutional capacities of high-income and low-income countries. Lack of national capacity is judged to be the key constraint to the development of HPSR. Recommendations from the summit in Mexico remain pertinent, and momentum towards their achievement must be accelerated through the ministerial forum in Mali and beyond.

Validation and experience with a simple continuous intra-abdominal pressure measurement technique in a multidisciplinary medical/surgical critical care unit.

BACKGROUND: Raised intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) may induce many adverse effects including the abdominal compartment syndrome. We evaluated a new technique for continuous monitoring of intra-abdominal pressure (CIAP) using a standard three-way bladder catheter in a diverse group of intensive care unit patients. METHODS: CIAP measured using a standard three-way bladder catheter was compared with five standard intermittent IAP (IIAP) measurements in 79 patients. RESULTS: Mean (standard deviation) CIAP was identical (15.4 mm Hg [5.8]) for CIAP and IIAP one minute after saline injection. Mean differences between methods were less than 1 mm Hg, and similar whether IIAP was measured at 1 minute, 2 minutes, 3 minutes, 4 minutes, or 5 minutes. Bland-Altman analysis comparing CIAP and IIAP (1 minute) revealed a mean difference (95% confidence interval) of -0.06 mm Hg (-0.51, 0.39). Limits of agreement were -4.12 mm Hg to 4.00 mm Hg. Considering gradations of IAH defined by the World Society of the Abdominal Compartment Syndrome, CIAP was sensitive for detecting slightly elevated IAP (>11 mm Hg) but is less sensitive for distinguishing between higher grades of IAH (e.g., pressures >20 mm Hg or 25 mm Hg). Limits of agreement were best for patients with IAP less than 20 mm Hg, surgical or traumatic diagnoses and for patients with BMI less than 26. CONCLUSIONS: Overall, CIAP is an accurate and simple means of measuring IAP when compared with the current standardized method. Elevated CIAP measurements should be confirmed with IIAP measurements if accurate grading is required until further validation and experience is obtained.

Indian community health insurance schemes provide partial protection against catastrophic health expenditure.

BACKGROUND: More than 72% of health expenditure in India is financed by individual households at the time of illness through out-of-pocket payments. This is a highly regressive way of financing health care and sometimes leads to impoverishment. Health insurance is recommended as a measure to protect households from such catastrophic health expenditure (CHE). We studied two Indian community health insurance (CHI) schemes, ACCORD and SEWA, to determine whether insured households are protected from CHE. METHODS: ACCORD provides health insurance cover for the indigenous population, living in Gudalur, Tamil Nadu. SEWA provides insurance cover for self employed women in the state of Gujarat. Both cover hospitalisation expenses, but only upto a maximum limit of US$23 and US$45, respectively. We reviewed the insurance claims registers in both schemes and identified patients who were hospitalised during the period 01/04/2003 to 31/03/2004. Details of their diagnoses, places and costs of treatment and self-reported annual incomes were obtained. There is no single definition of CHE and none of these have been validated. For this research, we used the following definition; "annual hospital expenditure greater than 10% of annual income," to identify those who experienced CHE. RESULTS: There were a total of 683 and 3152 hospital admissions at ACCORD and SEWA, respectively. In the absence of the CHI scheme, all of the patients at ACCORD and SEWA would have had to pay OOP for their hospitalisation. With the CHI scheme, 67% and 34% of patients did not have to make any out-of-pocket (OOP) payment for their hospital expenses at ACCORD and SEWA, respectively. Both CHI schemes halved the number of households that would have experienced CHE by covering hospital costs. However, despite this, 4% and 23% of households with admissions still experienced CHE at ACCORD and SEWA, respectively. This was related to the following conditions: low annual income, benefit packages with low maximum limits, exclusion of some conditions from the benefit package, and use of the private sector for admissions. CONCLUSION: CHI appears to be effective at halving the incidence of CHE among hospitalised patients. This protection could be further enhanced by improving the design of the CHI schemes, especially by increasing the upper limits of benefit packages, minimising exclusions and controlling costs.

The landscape of community health insurance in India: an overview based on 10 case studies.

The Indian health system is mainly funded by out-of-pocket payments. More than 80% of health care expenditure is borne by individual households. Only about 3% of the population, mostly those in the formal sector, benefit from some form of health insurance. Several Indian Non-Governmental Organisations (NGOs) have initiated Community Health Insurance (CHI) schemes within their existing development programmes. This article describes the principal features of the design and functioning of a selection of 10 CHI schemes and presents a brief overview of the current landscape of CHI in India. The schemes explicitly target the poorest and most vulnerable households in Indian society-scheduled tribes, scheduled castes and poor women. Three CHI management models can be distinguished. The first model consists of local NGOs acting as both insurer and provider. In the second model, the NGO is the insurer but does not itself provide care, which is then purchased from a private provider. In the third model, the NGO neither does provide health care nor acts as an insurer: the NGO, on behalf of a community, links with an insurer and purchases health care from a provider. The benefit packages generally include both primary and secondary care and most of the providers are in the private sector. Most of the schemes require external resources for financial sustainability. There is currently little information on the impact of CHI schemes on the performance of local health systems and more research is warranted in that respect.

Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia.

Based on a household survey conducted in Tbilisi, Georgia, in 2000, this paper examines current patterns of health care-seeking behaviour and the extent of out-of-pocket payments. Results show that health care services are a financial burden and that private (out-of-pocket) payment creates financial barriers to accessing health services. Members of the poorest households are less likely to seek care than people from more affluent households, and devote a higher share of household monthly expenditure to health care. Households have adopted various strategies to overcome these financial barriers, but the strategies are likely to contribute to both declining economic status and worsening health outcomes. The paper provides an evidence base to help direct future policy reform in Georgia. Government needs to: (1) prioritize public financing of services for the poor, in particular through amending the Basic Benefit Package so that it better reflects the needs of the poor; (2) promote the quality and utilization of primary care services; (3) address the issue of rational drug use; and (4) consider mobilizing out-of-pocket payments on a pre-paid basis through formal or community-based risk pooling schemes.

Improving the health of the global poor.

We analyzed the technical basis for a major global program to reduce disease among the poor. Effective interventions exist against the few diseases which most account for excess mortality among the poor. Achieving high coverage of effective interventions requires a well-functioning health system, as well as overcoming a set of financial and nonfinancial constraints. The annual incremental cost would be between $40 billion and $52 billion by 2015 in 83 low-income and sub-Saharan African countries. Such a program is feasible and would avoid millions of child, maternal, and adult deaths annually in poor countries.