Ethical issues in healthcare financing

The four goals of good healthcare are to relieve symptoms, cure disease, prolong life and improve quality of life. Access to healthcare has been a perpetual challenge to healthcare providers who must take into account important factors such as equity, efficiency and effectiveness in designing healthcare systems to meet the four goals of good healthcare. The underlying philosophy may designate health as being a basic human right, an investment, a commodity to be bought and sold, a political demand or an expenditure. The design, policies and operational arrangements will usually reflect which of the above philosophies underpin the healthcare system, and consequently, access. Mechanisms for funding include fee-for-service, cost sharing (insurance, either private or government sponsored) free-of-fee at point of delivery (payments being made through general taxes, health levies, etc) or cost-recovery. For each of these methods of financial access to healthcare services, there are ethical issues which can compromise the four principles of ethical practices in healthcare, viz beneficence, non-maleficence, autonomy and justice. In times of economic recession, providing adequate healthcare will require governments, with support from external agencies, to focus on poverty reduction strategies through provision of preventive services such as immunization and nutrition, delivered at primary care facilities. To maximize the effect of such policies, it will be necessary to integrate policies to fashion an intersectoral approach.

Assumptions about disease treatment challenged in a family health clerkship: views of first clinical year medical students

CONTEXT

During a family health clerkship at the University of The West Indies, students are expected to acquire individual and community diagnosis skills and the ability to relate the two, as well as acquire knowledge of other community agencies involved in health care.

OBJECTIVE

To determine the main assumptions related to disease treatment, which students have had to re-think after engaging in this clerkship.

METHODS

End of clerkship assessments were carried out from two successive groups of third year medical students (n=64) at the University of West Indies, Jamaica. Students were asked to "list two assumptions regarding treating disease that have been challenged by your experience". A subsequent content analysis was done.

RESULTS

Fifty-five students (86%) completed the assessment. All assumptions were listed (n=99) and similar issues were linked into emerging themes. Twenty-five groups of assumptions produced seven main themes: "Issues related to compliance" (27.3%),"Patient's treatment is mainly physical" (17.2%), " Superiority of western medicine over alternative" (15.2%), "Patients' health seeking behavior and attitudes" (12.1%), " The extent of the contribution of social factors on health" (12.1%) and "Patients' knowledge and understanding of health" (7.0%).

CONCLUSION

The majority of students examined felt challenged on three themes: relating to issues of compliance, treating the "whole" patient not just the physical, and the superiority of western medicine over alternative. The three most popular individual assumptions were; patients have a mindset that favours compliance, medication affordability does not affect compliance and treatment is independent of social and environmental conditions.

Health promotion: issues and answers

In recent years, increased attention has been given to the development of health promotion programmes in a number of countries worldwide. Although health promotion itself is not new, a number of issues have emerged as the underlying concepts are articulated and put into practice. These relate to its relevance and ownership and to practical issues such as measurement of outcomes. This article provides a brief discussion on some of these issues and makes reference to a Caribbean framework for implementing health promotion.

Curriculum development in community health: drift or shift?

The curriculum in community health is best described as eclectic and dynamic. Its relevance is maintained by its response to the macro-environment; this response, whether innovative or otherwise, may be incremental on the one hand or feature wholesale change consequent on radical rethinking on the other. This paper reviews the content of the emerging curriculum in community health at the University of the West Indies, Jamaica, and attempts to discern the process of change and the factors which have informed these developments.

Narrow-linewidth diode laser using a fiber-optic ring resonator

Experimental results of linewidth reduction in AlGaAs diode lasers with frequency-selective Rayleigh scattering from a fiber-optic ring resonator are presented. The intermediate-frequency signal produced by two such lasers is shown to have less than a 100-Hz intermediate-frequency linewidth. Self-homodyning measurements indicate an estimated laser linewidth of 0.6 Hz. Observing the intermediate-frequency beat signal and a Fabry-Perot interferometer, we demonstrate frequency mode stability and tuning. This tuning allowed us to lock a heterodyne optical phase-locked loop successfully. The narrow-linewidth ring laser also produced a stimulated Brillouin scattering wave.

Recent developments in low-cost screening and assessment of childhood disabilities in Jamaica. Part 2: Assessment

This paper summarises the requirements and criteria for assessment of childhood disabilities. It reviews recent research carried out in Jamaica and outlines procedures for medical and psychological assessment used in the International Epidemiological Study of Childhood Disability as well as local experience in community-based rehabilitation. While the medical assessment procedures were considered to be validated, there is an urgent need for local research and development in psychological assessment. These approaches, while not perfect as yet, bring the possibility of local community capability closer. They will require changes in professional attitudes, training of health and educational personnel, and changes in the service systems, so that screening and assessment can be integrated into existing services. However, although this will obviate the need for new, specialised administrations, improved linkages and lines of referral will be necessary.

Changes in material resource levels in Jamaica's primary health care services between 1984 and 1991/1992

Jamaica's primary health-care services have been in a process of development since the 1970s. In 1984, a large management study collected data on levels of material resources (basic facilities, utilities, furniture, equipment and supplies items). Since 1984, serious staff shortages have affected the services, and there have been economic constraints, as well as a major hurricane. In order to measure changes over subsequent years, data on material resources were again collected in 1991/1992, using the same sample of 65 types 2 and 3 health centres as in 1984. Data were collected by interview with health centre staff. Results, whilst showing various changes item-by-item, showed constancy or minor improvements overall in levels of resources. Type 2 health centres continued to have lower resource levels than type 3s, even though the methodology allowed for their different needs where appropriate. Staff members' opinions of condition and adequacy of resources had become more positive than before. It was concluded that, in terms of material resources, activities within the primary health-care sector have offset the adverse effects of the macro-environmental conditions affecting the health centres. This method of material resource monitoring has implications for quality assessment of health facilities in primary health-care.

Identification of childhood disability in Jamaica: the ten question screen

This is the first in a series of papers that report the testing of two instruments for the identification and assessment of childhood disability by community workers (CWs) in Third World countries. It is part of the International Epidemiologic Study on Childhood Disability. The Ten Question Screen (TQ) was used as the main instrument to identify disability in a two stage population-based survey of 5478 children aged 2-9 years in Clarendon, Jamaica. In the second stage, TQ positive and 8% of the screen negative controls were professionally assessed by a doctor and a psychologist using standard criteria based on the main classification system of the ICIDH. Sensitivity of the TQ as a whole varied in different strata of the group and amongst different disabilities, from perfect in girls under 6 years, fits and motor disabilities and for serious disability in all group except boys over 5 years with cognitive disability. Specificity was good but the false positive rate was unacceptably high at 74%. It was concluded, firstly, that the validation of a simple questionnaire of perceptions of behaviour against objective measurements of impairments was perhaps not fair to the TQ. In spite of this, the TQ would be a very useful instrument in collecting disability data or for identifying people in need of rehabilitation help, if a way of reducing false positives could be found.

Estimates of the prevalence of childhood seizure disorders in communities where professional resources are scarce: results from Bangladesh, Jamaica and Pakistan

Although numerous estimates of the prevalence of seizure disorders in populations in the less developed world have now been published, these estimates are difficult to interpret due to lack of comparability of study methods and criteria for case definition. The results reported in this paper are from a large, collaborative study of disabilities in 2- to 9-year-old children in which standard research procedures and case definitions were used in three diverse populations (located in Bangladesh, Jamaica and Pakistan). A two-phase study design (screening followed by professional evaluations) was used in this study allowing for the professional evaluation to serve as the criterion in the estimation of prevalence, even for rare disorders. As a result, the prevalence estimates reported here have a high degree of comparability across populations and exhibit unusually strong validity for population surveys. Febrile seizures were the most common type of seizure history in all three populations, with point estimates of lifetime prevalence ranging from 10.9 to 62.8 per 1000. The lifetime prevalence rates of epilepsy (recurrent unprovoked seizures) ranged from 5.8 to 15.5 per 1000. Lifetime prevalence rates of neonatal, all provoked and all unprovoked seizures, as well as estimates of the prevalence of active epilepsy, are also reported.

The prevalence of childhood disability and related medical diagnoses in Clarendon, Jamaica

In a population-based survey in a defined area in the parish of Clarendon, Jamaica, the prevalence of six types of childhood disabilities was sought. All children aged 2-9 years who screened positive for disability, with 8% of children screening negative (out of a total of 5,468 children), were assessed by a physician and a psychologist. Disabilities were categorised by types and levels of severity. The estimated prevalence rate for all types and levels of disabilities was 93.9 per 1,000 children and for serious disability was 24.9 per 1,000. The rates for specific disabilities showed wide variation (cognitive, 81/1,000; speech, 14/1,000; visual, 11/1,000; hearing, 9/1,000; motor, 4/1,000; seizure, 2/1,000). Of the disabled children, 70% had only one disability, 23% had two and 6% had three or four disabilities. If disability is to be seen as a major outcome of a range of interacting factors, then these prevalence rates, taken with the specific aetiologies, would provide a framework for planning preventive and rehabilitative interventions.

Service needs of children with disabilities in Jamaica

We investigated the service needs of children attending a medical assessment as part of a two stage survey of 2 to 9-year-old children in mid and south Clarendon, Jamaica. Parents were asked about symptoms relating to six different disabilities: visual, hearing, speech, motor, cognitive and fits. Following medical and psychological assessment, a diagnosis of mild, moderate, severe or no disability was made. For children with disabilities, the frequencies of five possible types of intervention recommended by the physician were analysed and related to the prevalence of the six disabilities in the parish. To estimate the needs of the Jamaican child population the figures were extrapolated based on an estimate of 1 million children under the age of 15 years. These needs were then compared with places in existing services. Of the disabled children, 62% needed special education, 29.5% needed community-based services, 21% needed spectacles, 21% needed specialist referral, and 6% required medical treatment. Although the vast majority of these needs are not met, many more could be met in the community if existing health and education personnel are trained in basic techniques of screening and assessment.

The prevalence of health insurance in a Jamaican suburb and its correlations with service utilisation

The prevalence of health insurance in a low-income Jamaican community was determined from a systematic sample of 103 households. A household prevalence for health insurance of 32 per cent was found. Differentials in health service utilisation were more striking for private practitioner services where the highest correlation with coverage was found (r = 0.346, p less than 0.001). A negative correlation (r = -036, N.S. with local health centre utilisation was obtained. For every 100 people attending a private facility, 33 had health insurance coverage. The level of health insurance coverage in the community and its impact on service utilisation would suggest the possibility of harsh economies in the health sector, forcing consumers in low-income groups to seek a buffer for the expenses incurred from needs unmet by the public services. Part of this favourable prevalence of health insurance may also be due to job-related coverage.

The electoral register as a sampling frame in a community health survey

Experience with the electoral register as a sampling frame in a cross-sectional health study of a Jamaican community is outlined. A satisfactory yield of 83.7% (of possible minimum) was obtained with non-sample or wastage accounting for 7.3% of the chosen sample. The social organisation of the community is seen as limiting the applicability of the register, but overall, it presents itself as a potentially useful tool in community health surveys.