Health system reform. Physicians' views on the critical choices

Perceptions and attitudes of health professionals in kenya on national health care resource allocation mechanisms: a structural equation modeling

Background

Health care resource allocation is key towards attaining equity in the health system. However, health professionals’ perceived impact and attitude towards health care resource allocation in Sub-Saharan Africa is unknown; furthermore, they occupy a position which makes them notice the impact of different policies in their health system. This study explored perceptions and attitudes of health professionals in Kenya on health care resource allocation mechanism.

Method

We conducted a survey of a representative sample of 341 health professionals in Moi Teaching and Referral Hospital from February to April 2012, consisting of over 3000 employees. We assessed health professionals’ perceived impact and attitudes on health care resource allocation mechanism in Kenya. We used structural equation modeling and applied a Confirmatory Factor Analysis using Robust Maximum Likelihood estimation procedure to test the hypothesized model.

Results

We found that the allocation mechanism was negatively associated with their perceived positive impact (-1.04, p < .001), health professionals’ satisfaction (-0.24, p < .01), and professionals’ attitudes (-1.55, p < .001) while it was positively associated with perceived negative impact (1.14, p < .001). Perceived positive impact of the allocation mechanism was negatively associated with their overall satisfaction (-0.08) and attitude (-0.98) at p < .001, respectively. Furthermore, overall satisfaction was negatively associated with attitude (-1.10, p <.001). On the other hand, perceived negative impact of the allocation was positively associated with overall satisfaction (0.29, p <.001) but was not associated with attitude.

Conclusion

The result suggests that health care resource allocation mechanism has a negative effect towards perceptions, attitudes and overall satisfaction of health professionals who are at the frontline in health care. These findings can serve as a crucial reference for policymakers as the Kenyan health system move towards devolving the system of governance.

Are physicians willing to ration health care? Conflicting findings in a systematic review of survey research

BACKGROUND

Several quantitative surveys have been conducted internationally to gather empirical information about physicians' general attitudes towards health care rationing. Are physicians ready to accept and implement rationing, or are they rather reluctant? Do they prefer implicit bedside rationing that allows the physician-patient relationship broad leeway in individual decisions? Or do physicians prefer strategies that apply explicit criteria and rules?

OBJECTIVES

To analyse the range of survey findings on rationing. To discuss differences in response patterns. To provide recommendations for the enhancement of transparency and systematic conduct in reviewing survey literature.

METHODS

A systematic search was performed for all English and non-English language references using CINAHL, EMBASE, and MEDLINE. Three blinded experts independently evaluated title and abstract of each reference. Survey items were extracted that match with: (i) willingness to ration health care or (ii) preferences for different rationing strategies.

RESULTS

16 studies were eventually included in the systematic review. Percentages of respondents willing to accept rationing ranged from 94% to 9%.

CONCLUSIONS

The conflicting findings among studies illustrate important ambivalence in physicians that has several implications for health policy. Moreover, this review highlights the importance to interpret survey findings in context of the results of all previous relevant studies.

Factors affecting primary care physicians’ perceptions of health system reform in Israel: Professional autonomy versus organizational affiliation

This paper examines primary care physicians' perceptions of a National Health Insurance Law that introduced managed competition into Israel's health care system, and the factors affecting their perceptions. Between April and July 1997, we conducted a mail survey of primary care physicians employed by Israel's four health plans (which are managed care organizations). Eight hundred questionnaires were returned, representing a response rate of 86%. The findings indicate that, overall most physicians support the components of the National Health Insurance Law with statistically significant differences among physicians by health plan. Multivariate analysis revealed that, contrary to theoretical expectations, a perceived decrease in professional autonomy and in the status of the profession following reform did not significantly affect attitudes toward national health insurance. These findings highlight the need for additional empirical studies to further examine theoretical contentions about the implications of infringing on the professional autonomy and the dominant status of physicians. The principal and most interesting finding of this study was the independent effect of health plan affiliation on physicians' attitudes toward each of the five components of the National Health Insurance Law, after controlling for background characteristics, for the reform's perceived effect on the physicians' autonomy and status in the health plan, and for the reform's perceived effect on the level of health plan services and the health plan's financial situation. We found that physicians' perceptions tended to conform to the formal position of their health plan, suggesting the need to analyze the attitudes of physicians in their organizational context, rather than treating them as members of a uniform professional community.

Americans' political participation in the 1993-94 national health care reform debate

The health politics and policy communities are still struggling with the question of "what went wrong" in the 1993-94 health care reform effort. Here I identify which Americans were politically active and inactive during the health care reform debate to explore the role political participation may have had in determining the outcome of the debate. Using data from a national and California random-sample telephone surveys, and controlling for other demographic attributes, I found that those who engaged in political activity specifically related to health care reform were disproportionately more likely to be self-identified conservatives, less likely to favor an employer mandate plan, more likely to be fifty to sixty-four years old, more likely to be men, and more likely to have greater interest in and knowledge of the health care issue. Even in California, where a single-payer proposal was on the November ballot, self-identified liberals were no more likely to engage in political activity on health care reform than were moderates or conservatives. I consider implications for the reform outcome given that liberals, the elderly, and those favoring the employer mandate proposal were all disproportionately "silent" during this debate, and finally I discuss the potential for mobilization during future debates.