Health policy in times of austerity—A conceptual framework for evaluating effects of policy on efficiency and equity illustrated with examples from Europe since 2008

The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

Socioeconomic inequality in knowledge about HIV/AIDS over time in Ethiopia: A population-based study

Socioeconomic inequality in comprehensive knowledge about HIV/AIDS can hinder progress towards ending the epidemic threat of this disease. To address the knowledge gap, it is essential to investigate inequality in HIV/AIDS services. This study aimed to investigate socioeconomic inequality, identify contributors, and analyze the trends in inequality in comprehensive knowledge about HIV/AIDS among adults in Ethiopia. A cross-sectional study was conducted using 2005, 2011, and 2016 population-based health survey data. The sample size was 18,818 in 2005, 29,264 in 2011, and 27,261 in 2016. Socioeconomic inequality in comprehensive knowledge about HIV/AIDS was quantified by using a concentration curve and index. Subsequently, the decomposition of the concentration index was conducted using generalised linear regression with a logit link function to quantify covariates' contribution to wealth-based inequality. The Erreygers' concentration index was 0.251, 0.239, and 0.201 in 2005, 2011, and 2016, respectively. Watching television (24.2%), household wealth rank (21.4%), ever having been tested for HIV (15.3%), and education status (14.3%) took the significant share of socioeconomic inequality. The percentage contribution of watching television increased from 4.3% in 2005 to 24.2% in 2016. The household wealth rank contribution increased from 14.6% in 2005 to 21.38% in 2016. Education status contribution decreased from 16.2% to 14.3%. The percentage contribution of listening to the radio decreased from 16.9% in 2005 to -2.4% in 2016. The percentage contribution of residence decreased from 7.8% in 2005 to -0.5% in 2016. This study shows comprehensive knowledge about HIV/AIDS was concentrated among individuals with a higher socioeconomic status. Socioeconomic-related inequality in comprehensive knowledge about HIV/AIDS is woven deeply in Ethiopia, though this disparity has been decreased minimally. A combination of individual and public health approaches entangled in a societal system are crucial remedies for the general population and disadvantaged groups. This requires comprehensive interventions according to the primary health care approach.

The influence of SYRIZA-ANEL Greek health policies on hospital efficiency

BACKGROUND

We analyse the impact of the three following categories of Health Policies (HP) carried out by the Greek SYRIZA-ANEL governments on the efficiency of Greek public general hospitals. These governments have implemented policies intended to change the rate of contributions to publicly funded healthcare (PCnH), policies to affect the volume and quality of publicly funded health care (PVQH) and those intended to affect the costs of publicly funded healthcare (PCH). A literary review of the PCnH. PVQH and PCH policies of the Greek SYRIZA-ANEL governments was carried out and an efficiency window-DEA study was executed using data from the Ministry of Health (MoH) and the Greek Statistical Authority (ELSTAT).

METHODS

The study was designed to assess the impact of PCnH. PVQH and PCH policies by the Greek SYRIZA-ANEL governments on the efficiency of Greek general hospitals. The data was collected from HEAL-Link scientific journals. Information on HPs was extracted from the work collected. The values of inputs and outputs used for the efficiency study were obtained from ELSTAT and Greek MoH databases.

RESULTS

HPs of the Greek SYRIZA-ANEL governments extend to all three HP categories of the sample used. These policies have a dual effect on both the inputs and outputs used in efficiency. Efficiency values exhibit fluctuations with good and bad years. The SYRIZA-ANEL governments seek to ensure more equality in access to health services. Some of the policies reduce costs and have a positive impact on efficiency, while others have the opposite effect. The increase in outputs achieved as a result of health policies is counter balanced by an increase in inputs.

CONCLUSIONS

The PCnH, PVQH and PCH policies of the SYRIZA-ANEL governance seem to have a dual orientation: some policies reduce the cost of a category and contain the total cost, thus positively contributing to an increase in efficiency. Certain policies are aimed more at fulfilling the criterion of equality in the provision of health services and thus the cost inevitably increases. From the window-DEA study, three relatively "good" years emerge (2015, 2016, 2018) and two "bad years" (2017, 2019). This analysis will be useful for further research on the effect of health policies on hospital efficiency in other countries and periods.

Involvement in Root Cause Analysis and Patient Safety Culture Among Hospital Care Providers

BACKGROUND

The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team.

OBJECTIVE

The aim of the study was to determine whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities.

METHODS

Using the original data from a cross-sectional survey of 5064 employees at a single university hospital in France, we analyzed the differences in HSOPS dimension scores according involvement in EFC activities.

RESULTS

Of 5064 eligible employees, 3888 (76.8%) participated in the study. Among the respondents, 440 (11.3%) participated in EFC activities. Experience feedback committee participants had a more developed patient safety culture, with 9 of the 12 HSOPS dimension scores significantly higher than EFC nonparticipants (overall effect size = 0.31, 95% confidence interval = 0.21 to 0.41, P < 0.001). A multivariate analysis of variance indicated that all 12 dimension scores, taken together, were significantly different between EFC participants and nonparticipants (P < 0.0001), independently of sex, hospital department, and healthcare profession category. The largest differences in scores related to the "feedback and communication about error," "organizational learning," and "Nonpunitive response to error" dimensions. The analysis of the subgroup of professionals who worked in a department with a productive EFC, defined as an EFC implementing at least five actions per year, showed a higher patient safety culture level for seven of the 12 HSOPS dimensions (overall effect size = 0.19, 95% confidence interval = 0.10 to 0.27, P < 0.001).

DISCUSSION AND CONCLUSIONS

Participation in EFC activities was associated with higher patient safety culture scores. The findings suggest that root cause analysis in the team's routine may improve patient safety culture.

Evidence and politics of patient experience in Ontario: The perspective of healthcare providers and administrators

BACKGROUND

Patient experience has a direct impact on patients' engagement in healthcare, their commitment to treatment plans, and their relationship with their healthcare providers, all of which can impact their health outcomes. The complexity of the healthcare system, the increasing health needs of the population, and the priority and knowledge differences among healthcare stakeholders impact how they conceptualize and seek to achieve the ideal patient experience and the weights that they give to different elements of this experience.

AIMS

This study sought to understand the perspectives of healthcare providers and administrators in Ontario regarding the factors affecting the patient experience.

MATERIALS & METHODS

Qualitative data were collected between April 2018 and May 2019. Twenty-one semi-structured interviews were conducted. Interviewees included physicians, nurses, optometrists, dietitians, quality managers, and policymakers. Thematic analysis was used to analyse the data, utilizing and extending a previously developed patient experience framework.

RESULTS

Several themes emerged in the data, and they represent two perspectives on patient experience: the biomedical perspective, which prioritizes health outcomes and gives high weights to healthcare experience factors that can be controlled by healthcare providers, while ignoring other factors, and the sociopolitical perspective, which recognizes the impacts of healthcare politics and the social context of health on patient experience in Ontario.

CONCLUSION

The study is timely in light of the current changes in the Ontario healthcare system and the healthcare reform started by the new government, as it sheds light on the possible negative impact of healthcare policy and politics on patient experience.

Supporting Innovative Person-Centred Care in Financially Constrained Environments: The WE CARE Exploratory Health Laboratory Evaluation Strategy

The COST CARES project aims to support healthcare cost containment and improve healthcare quality across Europe by developing the research and development necessary for person-centred care (PCC) and health promotion. This paper presents an overview evaluation strategy for testing 'Exploratory Health Laboratories' to deliver these aims. Our strategy is theory driven and evidence based, and developed through a multi-disciplinary and European-wide team. Specifically, we define the key approach and essential criteria necessary to evaluate initial testing, and on-going large-scale implementation with a core set of accompanying methods (metrics, models, and measurements). This paper also outlines the enabling mechanisms that support the development of the "Health Labs" towards innovative models of ethically grounded and evidenced-based PCC.

Construction of nursing knowledge in commodified contexts: A discussion paper

This original article outlines a theoretical path and posterior critical analysis regarding two relevant matters in modern nursing: patterns of knowing in nursing and commodification contexts in contemporary health systems. The aim of our manuscript is to examine the development of basic and contextual nursing knowledge in commodified contexts. For this purpose, we outline a discussion and reflexive dialogue based on a literature search and our clinical experience. To lay the foundation for an informed discussion, we conducted a literature search and selected relevant articles in English, Spanish, and Portuguese that included contents on patterns of knowing, commodification, and nursing published from 1978 to 2017. Globalization, commodification, and austerity measures seem to have negative effects on nursing. Work conditions are worsening, deteriorating nurse-patient relationships, and limiting reflection on practice. Nurses must develop knowledge to challenge and participate in institutional organization and public health policies. Development of nursing knowledge may be difficult to achieve in commodified environments. Consequently, therapeutic care relationships, healthcare services, and nurses' own health are compromised. However, by obtaining organizational, sociopolitical, and emancipatory knowledge, nurses can use strategies to adapt to or resist commodified contexts while constructing basic knowledge.

Alteridade ou austeridade: uma revisão acerca do valor da equidade em saúde em tempos de crise econômica internacional

Resumo Nas últimas décadas, o sistema capitalista, transformado por meio de crises mais agressivas e globais, tem submetido a sociedade à austeridade fiscal e tensionado a garantia dos direitos à saúde, como imposição para ampliar a eficiência e efetividade dos sistemas de saúde. A equidade em saúde, por outro lado, opera como fator protetor em relação aos efeitos nocivos da austeridade sobre a saúde da população. O objetivo deste artigo é analisar o efeito da crise financeira global quanto à valorização da equidade em saúde frente à efetividade nas comparações internacionais de eficiência dos sistemas de saúde na literatura científica. Realizada revisão integrativa, com busca nas bases de dados PubMed e BVS, de 2008-18, com análise cross-case. O equilíbrio entre equidade e efetividade deve ser buscado desde o financiamento até os resultados em saúde, de modo eficiente, como forma de fortalecimento dos sistemas de saúde. A escolha entre alteridade ou austeridade deve ser feita de forma explícita e transparente, com resiliência dos valores societais e princípios de universalidade, integralidade e equidade.

Organisational and financial consequences of the early discharge of patients treated for acute bacterial skin and skin structure infection and osteomyelitis in infectious disease departments in Greece, Italy and Spain: a scenario analysis

OBJECTIVE

The aim of the analysis is to assess the organisational and economic consequences of adopting an early discharge strategy for the treatment of acute bacterial skin and skin structure infection (ABSSSI) and osteomyelitis within infectious disease departments.

SETTING

Infectious disease departments in Greece, Italy and Spain.

PARTICIPANTS

No patients were involved in the analysis performed.

INTERVENTIONS

An analytic framework was developed to consider two alternative scenarios: standard hospitalisation care or an early discharge strategy for patients hospitalised due to ABSSSI and osteomyelitis, from the perspective of the National Health Services of Greece, Italy and Spain. The variables considered were: the number of annual hospitalisations eligible for early discharge, the antibiotic treatments considered (ie, oral antibiotics and intravenous long-acting antibiotics), diagnosis-related group (DRG) reimbursements, number of days of hospitalisation, incidence and costs of hospital-acquired infections, additional follow-up visits and intravenous administrations. Data were based on published literature and expert opinions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of days of hospitalisation avoided and direct medical costs avoided.

RESULTS

The total number of days of hospitalisation avoided on a yearly basis would be between 2216 and 5595 in Greece (-8/-21 hospital beds), between 15 848 and 38 444 in Italy (-57/-135 hospital beds) and between 7529 and 23 520 in Spain (-27/-85 hospital beds). From an economic perspective, the impact of the early discharge scenario is a reduction between €45 036 and €149 552 in Greece, a reduction between €182 132 and €437 990 in Italy and a reduction between €292 284 and €884 035 in Spain.

CONCLUSIONS

The early discharge strategy presented would have a positive organisational impact on National Health Services, leading to potential savings in beds, and to a reduction of hospital-acquired infections and costs.

Pharmacy, pharmaceuticals and public policy: Solving the puzzle

Increasing pressure on healthcare demand and delivery has resulted in the development of new roles and services for pharmacists. As current models of pharmacy practice continue to be evaluated, pharmacists must be involved in identifying new areas that may require research. In order to do so, the current vision of the future of pharmacy practice is discussed in this commentary. Issues such as adequate funding, professional competency and building strong interprofessional relationships are still identified as major barriers to change. These barriers have been grouped into the themes that form a conceptual model of the factors affecting the future of pharmacy practice, which have led to the development of key questions for the future.

The distribution of benefits under China's new rural cooperative medical system: evidence from western rural China

Background

China’s New Cooperative Medical Scheme (NCMS) enables insured citizens to enjoy the same benefit package by paying a flat-rate premium. However, it still remains uncertain whether economically disadvantaged enrollees receive insurance benefits that at least match those of non-disadvantaged enrollees. This article, therefore, estimates the distribution of benefits under the NCMS across economic groups and compares the magnitude of economic-related inequity changes in the NCMS benefits.

Methods

Data were drawn from two-wave large-scale representative and comparable cross-sectional household health survey datasets conducted in Shaanxi Province in 2008 and 2013. In total, 9506 (2008) and 38,010 (2013) NCMS enrollees were included. The benefits from the NCMS are measured in two ways: via the probability of receiving reimbursements and via the absolute amount of the obtained reimbursements. Two-part models were used to estimate the benefit distribution and to adjust benefits for health care needs. Concentration curve, dominance test of the concentration curve, and concentration index (CI) were used to estimate the overall degree of economic-related inequality. The degree of horizontal inequity was estimated via indirectly standardized measures based on the “equal treatment for equal needs” concept.

Results

Our results indicate that economically affluent groups were more likely to receive reimbursements from the NCMS, and these reimbursements were also higher. Positive need-adjusted CIs for the probability of receiving reimbursements (CIs: 0.2027/0.1056 in 2008/2013) and the absolute amount of reimbursements (CIs: 0.3002/0.1660 in 2008/2013) further suggest the existence of clear pro-rich horizontal inequities in the benefits distribution under the NCMS. Encouragingly, a decreasing trend could be observed from 2008 to 2013, which suggests that horizontal inequities in NCMS benefits that favored the rich decreased over the investigated period, while the level of insurance benefits improved.

Conclusions

Our study suggests that the benefits of NCMS are concentrated toward economically affluent groups. Although any trade-off between policy feasibility and equity has become a challenge for the formulation of social health insurance funding and benefit packages in developing countries, inequality can be gradually reduced through continuous adjustment of the medical insurance scheme, thus effectively targeting economically disadvantaged enrollees.

Mortality reductions from marginal increases in public spending on health

There is limited empirical evidence of the nature of any relationship between health spending and health outcomes in Australia. We address this by estimating the elasticity of health outcomes with respect to public healthcare spending using an instrumental variable (IV) approach to account for endogeneity of healthcare spending to health outcomes. Results suggest that, based on the conditional mean, a 1% increase in public health spending was associated with a 2.2% (p < 0.05) reduction in the number of standardised Years of Life Lost (YLL). Sensitivity analyses and robustness checks supported this conclusion. Further exploration using IV quantile regression indicated that marginal returns on public health spending were significantly greater for areas with poorer health outcomes compared to areas with better health outcomes. On average, marginal increases in public health spending reduce YLL, but areas with poorer health outcomes have the greatest potential to benefit from the same marginal increase in public health spending compared to areas with better health outcomes. Understanding the relationship between health spending and outcomes and how this differs according to baseline health outcomes can help meet dual policy objectives to improve the productivity of the healthcare system and reduce inequity.

Assessing the effect of standardized cost systems on financial performance. A difference-in-differences approach for hospitals according to their technological level

Promoting the improvement of standardized cost systems (CS) is one of the measures available to health policy makers for the purpose of improving efficiency in hospitals over the long-term. Nevertheless, very few studies evaluate the relationship between alternative CS and the costs really incurred. We use data from 242 hospitals of the Spanish National Health Service (NHS) between 2010 and 2013 in order to explore the determinants of the cost per adjusted patient day, using a difference-in-differences approach where the treatment is the implementation of an advanced CS. We also investigate if the association between advanced CS and unit cost is different depending upon the technological level of the hospital. Results show that hospitals with more advanced CS contained their costs better. However, the latter effect of advanced CS is lower in hospitals with a greater endowment of high technology. Results suggest that health authorities should support the development of CS, particularly in high-tech hospitals, which are usually larger and more complex hospitals that tend to accumulate a greater portion of NHS hospital sector expenditure.